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tibe  fIDebfcal  Epitome  Series 

DISEASES  OF  WOMEN 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS 


BY 


CHARLES   GARDNER   CHILD,  Jr.,  M.D.  (Yale) 

Clinical  Professor  of  Gynecology,  New  York  Polyclinic  Medical  School  and  Hospital; 

Attending  Gynecologist  to  the  City  Hospital;  Junior  Attending  Surgeon 

to    the  Woman's    Hospital 


SERIES    EDITED    BY 


VICTOR  COX  PEDERSEX,  A.M.,  M.D. 

Genitourinary    Surgeon    to    the  Outpatient    Departments  of    the  Nev:   York 
and  Hudson  Street  Hospital 


ILLUSTRATED    WITH    101     ENGRAVINGS 


LEA  &  FEBIGER 
PHILADELPHIA  AND  NEW  YORK 


Entered  according  to  Act  of  Congress,  in  the  year   1909,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


Q^5 


TO 


HENRY  McMAHON  PAINTER,  M.D. 

WITH    THE 

author's  warmest  admiration 
and  esteem 


(iii) 


PEEFACE. 


In  writing  this  small  work  there  has  been  no  attempt  made 
to  enter  the  field  so  well  and  so  exhaustively  covered  by  the 
larger  text-books  on  Diseases  of  Women,  but  to  present  to  the 
student  and  practitioner  as  concise  and  authoritative  a  treatise 
on  the  subject  as  is  consistent  with  brevity.  Much  valuable 
information  has  been  obtained  from  the  standard  text-books, 
and  from  the  works  of  Kelly,  Allbutt,  Playfair,  Eden,  Hart 
and  Barbour,  Findley,  Roberts,  Wertheim,  Michalitsch, 
Doderlein  and  Kronig,  Bovee,  and  Galabin. 

A  list  of  questions  has  been  added  at  the  end  of  the  book 
for  those  who  desire  to  use  it  as  a  quiz-compend. 

C.  G.  C,  Jr. 

New  York  City,  1909. 


(v) 


CONTENTS. 

CHAPTER  I. 
Development  and  Anatomy  of  the  Female  Genital  Organs       17 

CHAPTER  II. 
Causes  of  Diseases  of  Woman 27 

CHAPTER  III. 
History  and  Examination  of  the  Patient 29 

CHAPTER  IV. 

The  External  Genitalia:  Malformations.    Diseases.    Tumors. 

Hernise 36 

CHAPTER  V. 

The  Vagina:   Malformations.     Diseases.     Tumors      ....       49 

CHAPTER  VI. 

The  Uterus:  Malformations.     Anteflexion.     Displacements      .       60 

CHAPTER  VII. 

The  Uterus  (Continued):    Malignant  Diseases 78 

(vii) 


viii  CONTENTS 

CHAPTER  VIII. 

The  Uterus  (Continued) :    Benign  Tumors      ..,.,.       84 

CHAPTER  IX. 

The  Fallopian  Tubes:  Diseases.     Tumors.     Ectopic  Gestation        92 

CHAPTER  X. 
The  Ovaries:    Diseases.     Displacements.     Tumors    ....       97 

CHAPTER  XI. 
Ectopic  Gestation 103 

CHAPTER  XII. 
Diseases  of  the  Parametrium 107 

CHAPTER  XIII. 
Menstruation  and  its  Disorders Ill 

CHAPTER  XIV. 
The  Dynamics  of  the  Female  Pelvis 116 

CHAPTER  XV. 
Displacements  of  the  Uterus 120 

CHAPTER  XVI. 

General  Gynecological  Operative  Technique     ....      151 


DISEASES  OF  WOMEN. 


CHAPTER  I. 
DEVELOPMENT  OF  THE  FEMALE  GENITAL  ORGANS. 

In  the  human  embryo  the  first  organs  to  appear  are  the  two 
Wolffian  ducts,  which  are  situated  one  on  each  side  of  the 
vertebral  column,  and  which  connect  later  with  the  Wolffian 
bodies.  These  are  long  and  spindle-shaped,  reaching  from  the 
diaphragm  to  the  pelvis.  The  inner  two  develop  the  genital 
gland:  ovary  or  testicle;  the  outer  two  develop  the  Wolffian 
ducts  and  later  the  ducts  of  Miiller.  Finally,  the  Wolffian 
ducts  disappear,  while  the  ducts  of  Miiller  remain,  forming  the 
genital  tract.  By  the  beginning  of  the  sixth  month  these 
changes  are  complete;  the  upper  portions  of  the  ducts  of 
Miiller  have  remained  separate,  forming  the  Fallopian  tubes, 
while  the  lower  have  coalesced  to  form  the  uterus  and  vagina. 

The  development  of  the  external  genitals  from  the  ducts  of 
Miiller  begins  by  an  opening  into  the  allantois,  or  the  lower 
intestinal  tract.  In  the  genital  tubercle,  which  makes  its 
appearance  at  about  the  sixth  week,  a  depression  gradually 
develops  which  later  communicates  with  the  allantois;  this 
is  the  cloaca,  the  common  opening  of  the  intestinal  and  genital 
tracts.  Eventually  this  common  opening  becomes,  by  the 
formation  of  the  perineum,  divided  into  two,  the  genito- 
urinary and  the  anal.  From  the  urachus  is  developed  the 
bladder,  its  lower  end  becoming  contracted  to  form  the 
urethra.  As  the  result  of  an  imperfect  fusion  between  these 
2  (17) 


18       DEVELOPMENT  OF  FEMALE  GENITAL  ORGANS 

ducts  various  errors  in  development,  from  a  partial  to  a  com- 
plete arrest,  may  occur,  giving  rise  to  numerous  malformations, 
such  as  an  entire  absence  of  the  uterus,  a  rudimentary  uterus, 


Fig.   1 


Human  embryo  of  thirty-five  days  (front 
view):  3,  left  external  nasal  process;  4, 
superior  maxillary  process;  5,  lower  maxil- 
lary process;  z,  tongue;  b,  aortic  bulb;  &', 
first  permanent  aortic  arch;  b  ,  second 
aortic  arch;  b  ,  third  aortic  arch,  or  ductus 
Botalli;  y,  the  two  filaments  to  the  right  and 
the  left  of  this  letter  are  the  pulmonary 
arteries,  which  begin  to  be  developed;  c,  the 
stem  of  the  superior  cava  and  right  azygos 
vein;  c  ,  the  common  venous  sinus  of  the 
heart;  c" ,  the  common  stem  of  the  left  vena 
cava  and  left  azygos;  o' ,  left  auricle  of  the 
heart;  v,  right,  v  ,  left  ventricle;  ae,  lungs; 
e,  stomach;  /,  left  omphalomesenteric  vein; 
s,  continuation  of  the  same  behind  the 
pylorus,  which  becomes  afterward  the  vena 
porta;  x,  vitello-intestinal  duct;  a,  right 
omphalomesenteric  artery;  m, Wolffian  body; 
i,  gut;  n,  imibilical  artery;  u,  umbilical 
vein;  8,  tail;  9,  anterior,  10,  posterior  limb. 
The  liver  has  been  removed.  The  white 
band  at  the  inner  side  of  the  Wolffian  body 
is  the  genital  gland,  and  the  two  white  bands 
at  its  outer  side  are  the  Miillerian  and  the 
Wolffian  ducts.     (KoUiker,  after  Coste.) 


a  one-horned  uterus,  a  two-horned  uterus,  a  double  uterus,  a 
double  vagina,  etc.  These  will  be  considered  more  fully 
under  their  respective  headings. 


ANATOMY  OF  FEMALE  GENITAL  ORGANS 


19 


ANATOMY  OF  THE  FEMALE  GENITAL  ORGANS. 


The  external  genital  organs,  to  which  the  term  vulva  is 
usually  given,  consist  of  the  mens  veneris,  labia  majora,  labia 


Fig.  2 
mons  veneris 

k 


MEATUS 
URINARIUS 


Vulva  of  a  virgin.    The  labia  have  been  widely  separated.   (Testut.) 

minora,  clitoris,  vestibule,  meatus  urinarius,  hymen,  fossa 
navicularis,  fourchette,  and  perineum. 


20      DEVELOPMENT  OF  FEMALE  GENITAL  ORGANS 

The  mons  veneris  is  a  rounded  eminence  surmounting  the 
pubes,  composed  of  fatty  tissue  and  covered  by  integument 
and  hair. 

The  labia  majora  are  two  more  or  less  prominent  longi- 
tudinal folds  of  cutaneous  tissue  covered  by  hair  and  mucous 
membrane,  continuous  with  the  mucous  membrane  of  the 
genitourinary  tract.  They  enclose  a  quantity  of  areolar  and 
fatty  tissue  with  nutrient  vessels  and  nerves,  and  join  at  each 
extremity,  forming  the  anterior  and  posterior  commissures. 
Between  the  posterior  commissure  and  the  anal  margin  is  a 
space  about  an  inch  in  extent,  the  perineum.  The  labia  are  the 
analogue  anatomically  of  the  scrotum  in  the  male. 

The  labia  minora,  or  nymphse,  are  two  smaller  folds  situated 
within  the  labia  majora  extending  from  the  clitoris  downward 
and  outward  for  about  one  and  one-half  inches  on  each  side 
of  the  vaginal  orifice.  At  their  convergence  at  the  clitoris 
each  labium  divides  into  two  folds.  These  surround  the  glans 
clitoris,  forming  its  prepuce  above  and  the  frenum  below.  The 
nymphse  are  composed  of  mucous  membrane  covered  by  a 
thin  epithelial  layer.  They  contain  a  plexus  of  vessels  and 
numerous  large  mucous  crypts,  which  secrete  a  quantity  of 
sebaceous  matter. 

The  clitoris  is  an  erectile  structure,  the  analogue  anatomically 
of  the  corpora  cavernosa  of  the  penis,  and  is  an  elongated 
organ  partially  covered  by  the  anterior  extremities  of  the 
labia  minora,  and  connected  on  each  side  with  the  rami  of 
the  pubes  and  ischia  by  a  crus.  It  is  surmounted  by  a  small 
tubercle  of  spongy  erectile  tissue,  the  glans  clitoris.  Two 
corpora  cavernosa  of  erectile  tissue  enclosed  in  dense  fibrous 
tissue  compose  the  body  of  the  organ. 

The  vestibule  is  the  smooth  triangular  surface  situated 
between  the  clitoris  and  the  vaginal  entrance.  It  is  bounded 
on  either  side  by  the  labia  minora,  and  contains  the  meatus 
urinarius. 

The  hymen  is  a  thin  semilunar  fold  of  mucous  membrane 
spread  across  the  lower  part  of  the  vaginal  orifice. 


ANATOMY  OF  FEMALE  GENITAL  ORGANS  21 

The  glands  of  Bartholin  are  small  oblong  bodies,  two  in 
number,  situated  on  each  side  of  the  commencement  of  the 
vagina  above  the  deep  perineal  fascia,  and  are  the  analogues 
anatomically  of  the  glands  of  Cowper  in  the  male.  Each 
gland,  by  means  of  a  single  duct,  opens  upon  the  inner  surface 
of  the  nympha  adjacent,  just  external  to  the  hymen.  They 
are  compound  mucous  glands  and  secrete  a  colorless  tena- 
cious fluid  which  lubricates  the  vagina. 

Fig    3 


Internal  organs  of  generation:  a,  fimbriated  extremity  of  tube;  b,  Fallopian  tube; 
c,  broad  ligament,  upper  part;  d,  ovarian  vessels;  e,  vaginal  artery;  /,  os  externum; 
g,  uterine  artery;  h,  fimbria  ovarica.  (From  a  preparation  in  the  Museum  of  the 
Royal  College  of  Surgeons  of  England.) 

The  vagina  is  a  membranous  canal  extending  from  the 
vulva  to  the  uterus,  connecting  the  external  and  internal 
organs  of  generation.  In  length  it  is  between  four  and  six 
inches,  the  anterior  wall  being  from  one  to  two  inches  shorter 
than  the  posterior.  Lying  in  the  cavity  of  the  pelvis,  in  front 
of  the  rectum  and  behind  the  bladder,  its  direction  is  curved 
forward  and  downward,  following  first  the  line  of  axis  of  the 
cavity  of  the  pelvis,  and  afterward  that  of  the  outlet.  It  con- 
sists of  an  internal  mucous  lining  continuous  above  with  the 


22  DEVELOPMENT  OF  FEMALE  GENITAL  ORGANS 

mucous  membrane  lining  the  uterus,  and  below  with  the 
integument  covering  the  labia  majora.  Next  is  a  muscular 
coat  consisting  of  two  layers — an  external  longitudinal  and 
an  internal  circular.  Between  the  mucous  lining  and  the 
muscular  coat  is  a  layer  of  erectile  tissue.  The  lower  end  of 
the  vagina  is  surrounded  by  a  band  of  striped  muscular 
fibers  comprising  the  sphincter  vaginae. 


6'         6' 


Coronal  section  of  the  uterus  of  a  Coronal  section  of  the  uterus  of  a 

nuUiparous  woman.  multiparous  woman. 

1,  fundus;  2,  lateral  walls  of  the  body;  3,  cervix;  4,  isthmus;  5,  cavity  of  the 
body;  5',  internal  wall  of  the  body;  6,  cornu;  6',  opening  of  the  Fallopian  tube;  7, 
arbor  vitse;  8,  os  internum;  9,  os  externum;  10,  10',  lateral  fornices;  11,  posterior 
vaginal  wall.   (Testut.) 

The  internal  organs  of  generation,  or,  as  they  are  more  com- 
monly called,  the  pelvic  organs,  comprise  the  uterus.  Fallopian 
tubes,  and  ovaries  (Fig.  3). 

The  uterus  is  the  organ  of  gestation,  receiving  the  fecun- 


ANATOMY  OF  FEMALE  GENITAL  ORGANS 


23 


dated  ovum,  supporting  it  during  development,  and  expelling 
it  at  the  time  of  parturition.  It  is  a  pear-shaped  organ 
weighing  from  two  to  three  ounces,  situated  in  the  cavity  of 
the  pelvis  between  the  bladder  and  rectum,  with  its  base 
directed  upward  and  its  apex  downward.  The  upper  broad 
extremity  is  called  the  fundus  and  the  lower  constricted  por- 


FiG.  6 


Uterine  ligaments. 


tion  the  cervix.  The  body  of  the  uterus  gradually  narrows 
from  the  fundus  to  the  cervix,  its  anterior  surface  being 
covered  for  the  upper  three-fourths  by  peritoneum,  while  the 
lower  fourth  is  connected  with  the  bladder.  The  posterior 
surface  is  covered  by  peritoneum  throughout. 

The  uterus  is  suspended  in  the  pelvis  by  its  ligaments  (Fig.  6). 


24  DEVELOPMENT  OF  FEMALE  GENITAL  ORGANS 

These  are  eight  in  number:  Two  anterior  (utero vesical),  two 
posterior  (uterosacral),  two  lateral  (broad  ligaments),  and 
two  round  ligaments.  Of  these,  the  uterosacral,  holding  the 
cervix  well  up  in  the  hollow  of  the  sacrum,  and  the  round 
ligaments,  keeping  the  fundus  well  forward,  enter  most  actively 
into  the  support  of  the  uterus.  The  round  ligaments  are 
strong,  muscular,  fibrous  cords,  serving  to  hold  the  fundus 
forward.  In  pregnancy  they  increase  in  size  with  the  uterus, 
keeping  the  fundus  forward  in  its  excursion  upward  into  the 
abdominal  cavity,  and  after  parturition  involute  with  the 
uterus,  guiding  the  fundus  back  again  to  its  normal  position 
in  the  pelvis.  The  broad  ligaments  are  little  more  than  reflec- 
tions of  peritoneum,  serving  to  support  the  nutrient  vessels 
going  to  and  from  the  uterus. 

The  uterus  is  composed  of  three  coats,  enclosing  a  central 
cavity.  This  cavity  of  the  uterus  is  small  by  comparison 
with  the  size  of  the  organ,  and  communicates  with  the  Fal- 
lopian tubes  by  two  minute  openings  at  each  side  of  the 
fundus,  and  with  the  vagina  below  through  the  os  uteri. 
The  three  coats  of  the  uterus  are  the  external,  or  serous  coat, 
derived  from  the  peritoneum;  the  middle,  or  muscular  coat, 
which  forms  the  chief  substance  of  the  uterus,  and  consists 
of  bundles  of  unstriped  muscle  fibers  intermixed  with  areolar 
tissue,  bloodvessels,  lymphatics,  and  nerves;  the  internal,  or 
mucous  coat,  continuous,  through  the  fimbriated  extremity  of 
the  Fallopian  tubes,  with  the  peritoneum,  and  through  the  os 
uteri  with  the  mucous  membrane  of  the  vagina.  In  the  body 
of  the  uterus  this  mucous  membrane  is  lined  by  columnar 
ciliated  epithelium,  which  loses  its  ciliated  character  during 
pregnancy.  The  epithelium  in  the  lower  half  of  the  cervix  is 
of  the  stratified  variety. 

The  blood  supply  of  the  uterus  is  by  the  two  uterine  arteries 
from  the  internal  iliac  arteries.  They  run  a  remarkably 
tortuous  course  in  the  uterus  and  have  many  anastomoses. 
The  veins  are  larger  and  correspond  with  the  arteries.  The 
lymphatics  terminate  in  the  pelvic  and  lumbar  glands. 


ANATOMY  OF  FEMALE  GENITAL  ORGANS  25 

The  nerves  of  the  uterus  are  from  the  inferior  hypogastric, 
ovarian  plexuses,  and  third  and  fourth  sacral  nerves. 

At  different  periods  of  life  and  under  varying  circumstances 
important  changes  in  the  uterus  occur  in  form,  size,  and  posi- 
tion. The  uterus  of  fetal  life  is  more  an  abdominal  than  a 
pelvic  organ,  the  cervix  is  larger  than  the  body,  and  between 
the  two  there  exists  a  marked  anterior  angle  of  flexion.  At 
puberty  it  has  descended  into  the  pelvis,  the  body  is  larger 
than  the  cervix,  and  the  angle  of  flexion  has  disappeared. 
The  uterus  of  menstruation  enlarges,  becomes  more  vascular; 
the  superficial  part  of  the  mucous  lining  softens  and  is  cast 
off.  After  menstruation  rapid  cell  proliferation  occurs,  and  a 
fresh  mucous  membrane  is  formed. 

The  uterus  of  pregnancy  increases  greatly  in  size,  weighing 
from  one  to  three  pounds,  and  extends  well  above  the  pelvis 
into  the  abdominal  cavity.  After  parturition  it  returns  to 
nearly  its  former  size,  weighing  about  three  ounces ;  the  cavity, 
however,  always  remains  larger  than  in  the  virgin  state. 

The  uterus  of  old  age  atrophies,  becoming  much  smaller,  is 
pale  and  firm,  and  the  cervical  canal  is  often  obliterated. 

The  uterine  appendages  are  the  Fallopian  tubes,  the  ovaries 
and  their  ligaments,  and  the  round  ligaments. 

The  Fallopian  tubes,  or  oviducts,  convey  the  ova  from  the 
ovaries  to  the  uterine  cavity.  Two  in  number,  one  on  each 
side  and  situated  in  the  free  border  of  the  broad  ligaments, 
they  extend  from  each  horn  of  the  uterus  outward  to  the  sides 
of  the  pelvis.  Each  tube  is  about  four  inches  in  length  and 
has  a  small  canal  beginning  at  the  uterus  in  a  minute  opening, 
the  ostium  internum,  and  gradually  widening  to  its  termina- 
tion, the  ostium  abdominale,  by  which  it  communicates  with 
the  peritoneal  cavity.  The  JimhricB,  a  series  of  fringe-like  pro- 
cesses, surround  the  ostium  abdominale,  and  this  distal  end  is 
known  as  the  fimbriated  extremity.  There  are  three  coats  to 
the  tube:  an  external  or  serous,  derived  from  the  peritoneum; 
a  middle  or  muscular,  continuous  with  that  of  the  uterus;  and 
an  internal  or  mucous,  continuous  with  the  lining  of  the  uterus 


26      DEVELOPMENT  OF  FEMALE  GENITAL  ORGANS 

and  peritoneum,  and  covered  with  ciliated  columnar  epithelial 
cells. 

The  ovaries,  analogues  anatomically  of  the  testes  in  the 
male,  are  two  ovoid  bodies  situated  one  on  each  side  of  the 
uterus  on  the  posterior  aspect  of  the  broad  ligament,  below 
and  behind  the  Fallopian  tubes.  Each  is  connected  by 
its  anterior  margin  to  the  broad  ligament;  internally  to  the 
uterus  by  the  ovarian  ligament;  externally  to  the  fimbriated 
extremity  of  the  Fallopian  tube  by  a  short  ligamentous  cord. 
The  ovaries  are  white  in  color,  about  one  and  one-half  inches 
in  length,  three-quarters  of  an  inch  in  width,  and  one- third  of 
an  inch  thick,  and  weigh  about  2  drams  each. 

The  structure  of  the  ovary  consists  of  numerous  Graafian 
vesicles  embedded  in  a  network  of  stroma  and  invested  by  a 
serous  covering  derived  from  the  peritoneum.  This  differs 
widely,  however,  from  the  peritoneum  in  both  appearance 
and  structure,  and  is  known  as  the  germinal  epithelium  of 
Waldeyer. 

Each  ovary  contains  many  Graafian  vesicles  of  varying  size, 
according  to  their  degree  of  maturity.  These  contain  the  ova. 
As  the  Graafian  vesicle  matures  it  enlarges  in  size,  gradually 
approaching  the  surface  of  the  ovary,  and  at  the  time  of 
ovulation  ruptures,  liberating  the  ovum  that  it  may  pass  into 
the  Fallopian  tube.  In  this  it  is  assisted  by  the  finger-like 
processes  of  the  fimbriae  at  the  extremity  of  the  tube. 

Immediately  following  rupture  the  Graafian  vesicle  under- 
goes certain  changes,  formerly  thought  to  result  in  the  forma- 
tion of  a  corpus  luteum.  In  view  of  recent  investigations, 
however,  this  is  open  to  doubt,  and  it  would  seem  that  the 
corpus  luteum  plays  a  more  important  role  than  was  formerly 
supposed.  According  to  Fraenkel,  it  is  a  gland  "which  is 
renewed  every  four  weeks  in  women  during  reproductive  life, 
and  controls  the  nutrition  of  the  uterus  in  a  cyclic  fashion, 
preventing  it  from  relapsing  into  its  infantile  or  passing  into 
its  senile  condition,  and  prepares  as  well  the  endometrium 
for  the  reception  of  the  ovum.    If  the  ovum  be  fertilized,  the 


CAUSES  OF  DISEASES  OF  WOMAN  27 

corpus  luteum  continues  to  exist  and  to  maintain  the  raised 
nutrition  of  the  uterus  during  pregnancy,  but  if  fertihzation 
does  not  take  place  the  hyperemia  of  menstruation  merely 
is  produced  and  the  corpus  luteum  then  degenerates/' 

Lying  above  the  ovary  in  the  broad  ligament  between  it  and 
the  Fallopian  tube  is  the  organ  of  Rosenmiiller,  or  parovarium. 
This  is  the  remnant  of  a  fetal  structure,  and  in  the  adult  con- 
sists of  a  few  closed  convoluted  tubes  lined  with  epithelium, 
the  whole  connected  at  its  uterine  extremity  with  the  remains 
of  the  Wolffian  duct — the  duct  of  Gartner. 

The  ovarian  ligament  extends  from  the  inner  extremity  of 
the  ovary  to  the  superior  angle  of  the  uterus.  The  round 
ligaments,  two  in  number,  are  about  five  inches  in  length  and 
are  situated  between  the  layers  of  the  broad  ligament,  one  on 
each  side  of  the  uterus  in  front,  and  below  the  Fallopian  tube. 
They  pass  forward  and  outward  from  the  uterus,  through  the 
internal  abdominal  ring,  along  the  inguinal  canal,  and  out  at 
the  external  abdominal  ring. 

The  arteries  of  the  ovaries  and  Fallopian  tubes  are  the 
ovarians  from  the  aorta  anastomosing  with  the  termination  of 
the  uterine  arteries  as  they  enter  the  attached  bodies  of  the 
ovary.  The  veins  follow  the  course  of  the  arteries,  forming  a 
plexus  near  the  ovary,  the  pampiniform  plexus. 


CHAPTER  11. 

CAUSES  OF  DISEASES  OF  WOMAN. 

As  woman  possesses  certain  organs,  and  plays  a  part  in  life 
peculiarly  her  own,  one  should  naturally  expect  to  find  her 
subject  to  certain  diseased  conditions  more  or  less  dependent 
on  her  anatomy,  physiology,  and  mode  of  life. 


28  CAUSES  OF  DISEASES  OF  WOMAN 

The  most  frequent  causes  of  the  diseases  of  woman  may  be 
summed  up  under  the  following  headings: 

Civilization. — Among  primitive  people,  woman  is  noto- 
riously free  from  many  of  the  diseases  to  which  her  sister 
in  our  present-day  civilization  is  especially  prone.  As  we 
ascend  the  scale  of  civilization,  departing  from  a  natural  and 
adopting  an  artificial  mode  of  life,  we  find  that  Nature  enacts 
due  penalties  for  the  transgression  of  her  laws.  The  female 
among  savage  tribes  has  every  advantage  and  opportunity 
to  develop  physical  perfection,  and  her  endurance  suffers 
little,  if  any,  by  comparison  with  the  male.  How  different  is 
our  modern  system  when  the  young  girls  are  sent  early  to 
school  and  subjected  daily  to  long  hours  of  study,  often  in 
badly  ventilated  classrooms,  for  nine  months  in  the  year,  and 
this  at  the  time  of  puberty,  one  of  the  most  important  periods 
of  their  life  when  they  need  plenty  of  outdoor  exercise.  Surely, 
as  Goodell  says:  "If  woman  is  to  be  thus  stunted  and 
deformed  to  meet  the  ambitious  intellectual  demands  of  the 
day,  if  her  health  must  be  sacrificed  upon  the  altar  of  her 
education,  the  time  may  come  when  to  renew  the  wornout 
stock  of  this  Republic  it  will  be  necessary  for  our  young  men 
to  make  matrimonial  excursions  into  lands  where  educational 
theories  are  unknown." 

Menstruation. — Carelessness  and  neglect  of  this  function  is 
directly  responsible  for  many  of  its  disorders.  Physical  and 
mental  rest  at  this  time,  and  especially  at  puberty,  are  seldom 
practised,  but  the  daily  routine  is  gone  through  regardless  of 
consequences. 

Dress. — There  can  be  little  doubt  but  that  abdominal  con- 
striction, such  a  prominent  feature  in  woman's  present  mode 
of  dress,  is  an  important  predisposing  element.  The  con- 
traction of  the  normal  size  of  the  abdominal  cavity,  with  the 
subsequent  compression  and  displacement  of  its  viscera,  must 
of  necessity  produce  dynamic  changes  in  the  pelvis  that  cannot 
be  otherwise  than  injurious  to  the  pelvic  organs.  Tight 
lacing,  or  any  lacing,  aside  from  the  remote  effects  so  unnatural 


HISTORY  OF  THE  PATIENT  29 

a  practice  must  produce,  causes  marked  atrophy  of  the 
abdominal  muscles.  These  are  often  so  weakened  that  during 
labor  they  cannot  properly  assist  the  uterus  in  effecting 
delivery,  and  as  a  result  instrumental  interference,  with  its 
attendant  dangers,  becomes  necessary. 

Prevention  of  Conception. — This  practice  is  very  common 
among  civilized  women,  and  has  a  most  deleterious  effect 
upon  the  pelvic  organs,  as  well  as  upon  the  general  system. 
Insulted  and  disappointed  nature  exacts  penalties  far-reaching 
in  their  effects  and  little  dreamed  of  by  the  offender. 

Criminal  Abortion. — The  chief  danger  from  the  criminal 
interruption  of  gestation  is  sepsis.  This  may  be  acute  in 
character  and  fatal  in  its  termination,  or  chronic  in  nature, 
leading  to  permanent  injury  of  the  uterus  and  tubes,  sterility, 
and  chronic  invalidism. 

Childbirth.^ — Injuries  sustained  during  parturition  are  a 
frequent  cause  of  pelvic  disease. 

Venereal  Diseases. — Syphilis  exerts  its  usual  baneful 
influences,  but  gonorrhea  is  responsible  for  more  pathological 
lesions  in  the  female  pelvis  than  any  other  one  factor.  Its 
attack,  if  not  resulting  in  ultimate  loss  of  life,  always  leaves 
the  tissues  in  an  impaired  condition,  from  which  resolution  is 
rare.  It  is  doubtful  if  a  woman  once  infected  with  gonorrhea 
ever  recovers  from  its  ravages.  As  a  cause  of  sterility  its 
power  is  beyond  estimation. 


CHAPTER  III. 

HISTORY  OF  THE  PATIENT. 

A  general  medical  history,  as  well  as  a  special  gynecological 
history,  should  be  taken  of  each  case,  and  careful  inquiry 
into  the  woman's  mode  and  habits  of  life  should  always  be 
made. 


30  HISTORY  OF  THE  PATIENT 

In  taking  the  gjmecological  history  it  is  well  to  confine  all 
questions  to  certain  fixed  headings  designed  to  elicit  the 
information  desired  (Fig.  7).  Constant  study  should  be  given 
to  the  personal  equation,  and  every  effort  made  to  discover, 
and  to  place  at  their  proper  valuation  the  chief  symptoms 
complained  of  by  the  patient. 

In  order  to  systematize  the  history-taking  it  is  necessary 
to  have  a  regular  routine,  so  that  omissions  may  not  occur. 
At  the  first  interview  it  is  well  to  give  the  patient  an  oppor- 
tunity to  tell  her  story  first  before  proceeding  with  interro- 
gation, as  it  relieves  her  mind,  inspires  confidence,  and  affords 
the  physician  a  valuable  opportunity  to  study  the  personal 
equation.  The  history  should  comprise  the  following  data 
in  all  cases: 

Age. 

Social  Condition. — Whether  single,  married,  or  widowed. 
If  married,  the  length  of  time  spent  in  the  marital  state. 

Menstruation. — Age  and  state  of  health  at  onset,  regularity 
duration,  amount,  symptoms.      Date  and  character  of  last 
mensis.     Any  change  in  character  of  the  menstruation  since 
its  establishment  should  be  noted. 

Abortions  or  Miscarriages. — Number,  date,  period  of  gesta- 
tion, cause,  and  subsequent  convalescence. 

Children. — Number,  date,  and  nature  of  delivery,  whether 
easy,  difficult,  or  instrumental. 

Puerperia. — Whether  normal  or  protracted. 

Diseases  of  Childhood  (especially  the  exanthemata). — Func- 
tion of  the  bladder  and  bowels,  occupation,  and  all  details 
ascertainable  of  a  previous  operation  or  serious  illness  since 
reaching  puberty. 

Having  obtained  as  clear  a  history  as  possible,  the  physical 
examination  of  the  patient  should  follow.  On  the  degree  of 
thoroughness  with  which  this  is  possible  depends  the  success 
of  the  diagnosis,  and  every  effort  should  be  made  to  gain  the 
confidence  and  cooperation  of  the  patient,  otherwise  failure  in 
many  cases  will  result. 


E  a. 


X r 


2*  ■-  <" 


^SCL 


e 


(31  ) 


32  HISTORY  OF  THE  PATIENT 

Abdominal  Examination. — Inspectimi  should  disclose  any 
marked  deviation  from  the  normal  contour,  such  as  is  pro- 
duced by  the  presence  of  large  tumors  and  cysts.  When  these 
spring  from  the  pelvis,  the  prominence  usually  begins  abruptly 
at  the  symphysis  pubis  where  the  growth  leaves  the  pelvis. 
A  uniform  enlargement  is  more  usually  associated  with  ovarian 
cysts  and  general  uterine  fibrosis.  Tumors  of  the  appendages 
and  pedunculated  uterine  fibroid,  generally  give  an  irregular 
enlargement  more  marked  on  one  side  than  the  other.  Pal- 
pation should  decide  the  character  and  probable  so.urce  of 
any  tumor  present,  and  locate  any  points  of  tenderness  in  the 
region  of  the  appendix  vermiformis  or  in  the  inguinal  regions. 
The  inguinal  and  femoral  rings  should  be  examined  for  the 
presence  of  hernia. 

Vaginal  Examination. — Though  usually  avoided  during 
menstruation,  this  should  never  be  neglected  for  this  reason 
when  conditions  warrant  it.  The  bowels  and  bladder  should 
have  been  previously  thoroughly  emptied.  The  position  of 
the  patient  is  important,  and  a  suitable  examining  table  is  desir- 
able. If  in  bed,  the  patient  should  be  placed  on  her  back, 
crosswise  of  the  bed,  with  her  hips  well  over  the  edge,  legs 
flexed  and  supported  on  chairs  or  held  by  an  assistant.  The 
external  genitals  are  inspected  and  any  abnormality  noted. 
The  ductal  orifices  of  the  vulvovaginal  and  periurethral 
glands  are  examined  for  evidences  of  past  or  present  inflam- 
mation, of  which  gonorrhea  is  the  most  frequent  cause.  Insert- 
ing the  index  finger  into  the  vagina,  downward  pressure  is 
made  upon  the  perineum  for  its  resistance.  The  anterior  and 
posterior  vaginal  walls  are  examined  for  cystocele  or  rectocele. 
The  finger  is  then  passed  along  the  anterior  vaginal  wall  and 
parallel  to  it  until  the  cervix  is  reached,  when  its  size,  consist- 
ency, and  position  are  determined.  The  position  of  the  cervix, 
with  its  relation  to  the  axis  of  the  vagina,  is  an  important 
guide  to  the  position  of  the  uterus,  for  the  cervix  and  fundus 
cannot  materially  change  in  position  independently  of  one 
another.     With  the  cervix  in  normal  position — that  is,  per- 


BIMANUAL  EXAMINATION 


33 


pendicular  to  the  axis  of  the  vagina — the  fundus  must  be 
anterior,  in  normal  position  as  well.  When  the  cervix  is  in 
the  abnormal  position — that  is,  parallel  to  the  axis  of  the 


Fig.  8 


Correct  position  in  making  a  gynecological  examination.   (Goffe.) 

vagina — the  fundus  will  be  found  to  be  abnormally  located 
as  well,  and  will  always  be  in  one  of  three  positions,  viz., 
anteflexion,  retroversion,  or  retroflexion. 

Bimanual  Examination. — The  free  hand  is  placed  upon  the 
abdomen  just  above  the  brim  of  the  pelvis  and  firm,  steady 
pressure  made  toward  the  uterus,  gradually  pressing  the 
abdominal  wall  inward  toward  the  pelvis.  If  the  abdominal 
muscles  are  very  tense,  relaxation  may  be  obtained  by  eleva- 
ting the  shoulders  and  flexing  the  thighs  upon  the  abdomen. 
3 


34 


HISTORY  OF  THE  PATIENT 


The  index  finger  in  the  vagina  now  seeks  the  posterior  fornix 
and  gently  taps  the  cervix  toward  the  abdominal  hand.  If 
the  fundus  is  anterior  its  impact  will  be  felt  by  the  abdominal 
hand,  and  the  vaginal  finger,  palpating  the  anterior  fornix, 
distinguishes  between  normal  anteversion  of  the  uterus  and 
anteflexion.  In  anteversion  there  is  only  a  slight  curve  in  the 
line  between  cervix  and  fundus,  while  in  anteflexion  there  is 
a  marked  angle  of  flexion  readily  appreciated  by  the  examin- 
ing finger,  and  the  fundus,  palpated  between  the  two  hands. 


Fig.  9 


Graves'  speculum. 


is  small  and  lies  under  the  symphysis.  If  the  fundus  is  not 
located  anteriorly  the  vaginal  finger  in  the  posterior  fornix 
follows  up  the  cervix,  and  in  retroflexion  feels  the  rounded 
fundus  lying  back  in  the  hollow  of  the  sacrum,  with  a  marked 
angle  of  flexion  between  fundus  and  cervix.  Retroversion,  if 
not  actually  palpated,  may  be  inferred  by  exclusion.  Enlarge- 
ments of  the  uterus  and  tumors  of  the  uterus  are  most  certainly 
recognized  by  the  bimanual  examination.  When  the  location 
of  the  uterus  has  been  determined  its  size  and  mobility  should 
be   noted,   and   the  pelvis   examined   for   adhesion    bands, 


EXAMINATION  WITH  THE  SPECULUM  35 

exudates,  tumors,  involvements  of  the  appendages,  etc. 
(For  complete  diagnosis,  see  special  chapters.)  The  normal 
appendages  are  difficult  and  at  times  impossible  to  palpate, 
as  both  the  tube  and  ovary  easily  elude  the  fingers,  and  differ 
very  little  in  resistance  from  the  surrounding  structures. 

Rectal  Examination. — The  internal  examination  made  per 
rectum  is  often  of  great  value,  especially  in  retroflexion  and 
small  tumors  in  the  pouch  of  Douglas.  In  virgins  it  should 
always  be  the  method  of  election. 

Fig.   10 


Sims'  speculum. 


Examination  with  the  Speculum. — Following  the  bimanual 
examination,  the  vagina  and  cervix  should  be  carefully 
inspected.  This  is  only  possil)le  by  retracting  the  vaginal 
walls  with  a  proper  speculum.  These  are  of  three  kinds:  the 
tubular,  the  grooved  or  Sims,  and  the  valvular.     The  first  of 


36  THE  EXTERNAL  GENITALIA 

these  is  now  seldom  used.  In  introducing  the  speculum  the 
labia  are  separated,  the  index  finger  introduced  into  the  vagina 
retracts  the  posterior  vaginal  wall,  and  the  speculum  is  then 
introduced  up  to  the  cervix.  The  separation  of  the  blades  of 
the  speculum  should  be  so  manipulated  as  to  expose  the  cervix 
to  full  view  when  any  pathological  lesion  may  readily  be  seen. 


CHAPTER  IV. 

THE  EXTERNAL  GENITALIA. 

MALFORMATIONS  OF  THE  EXTERNAL  GENITALIA. 

Malformations  arise  as  the  result  of  defective  development 
in  either  the  genital  eminence,  the  genital  folds,  the  genital 
furrow,  or  the  genital  ridge. 

Absence  of  the  vulva  is  a  rare  condition,  usually  associated 
with  absence  of  the  internal  organs  of  generation  as  well. 
Partial  absence  associated  with  normally  formed  internal 
organs  is  of  more  common  occurrence. 

Double  vulva  is  an  exceedingly  rare  condition. 

Infantile  type  of  vulva  may  persist  after  puberty.  This 
anomaly  is  usually  accompanied  by  defective  development 
of  the  uterus  and  appendages. 

With  atresia  of  the  vulva  there  is  usually  found  also  a  com- 
munication between  the  vagina,  bladder,  and  rectum.  Com- 
plete atresia  is  rare  and  the  fetus  is  seldom  viable.  Partial 
atresia  is  of  more  frequent  occurrence. 

Hypospadias  is  a  persistence  of  the  urogenital  sinus,  both 
urine  and  menstrual  fluid  escaping  through  a  common  open- 
ing in  the  base  of  the  clitoris,  which  is  usually  hypertrophied. 
In  this  condition  doubt  often  arises  as  to  the  sex  of  the  fetus. 

Epispadias  is  a  defect  in  development  of  the  upper  wall  of 
the  urethra  whereby  the  urethra  appears  as  a  groove  passing 
upward  under  the  symphysis  to  the  bladder. 


VULVITIS  37 

The  clitoris  may  be  entirely  wanting,  bifid,  or  hypertrophied; 
the  latter  is  the  most  usual  anomaly.  It  is  frequently  found 
entirely  covered  by  a  redundant  or  adherent  prepuce. 

The  hymen  may  be  double,  absent,  or  imperforate.  Many 
anomahes  in  form  and  structure  exist,  but  are  of  little  practical 
importance.  The  imperforate  hymen  causes  retention  of  the 
menstrual  fluid,  and  the  abnormally  rigid  hymen  causes 
dyspareunia. 

Hermaphroditism. — This  term,  used  by  the  older  writers 
to  designate  cases  which  they  considered  as  possessing  the 
organs  of  both  sexes,  is  now  used  to  indicate  those  in  which 
the  sex  is  doubtful.  In  ancient  Rome  these  individuals  were 
destroyed,  while  in  the  East  they  were  deified.  In  the  human 
embryo  there  is  a  stage  in  development  when  it  is  impossible 
to  foretell  the  sex.  Whether  the  sexual  gland  will  become 
testicle  or  ovary;  whether  the  Miillerian  ducts  or  the  Wolf- 
fian ducts  atrophy;  whether  the  genital  tubercle  become  a 
penis  or  a  clitoris,  are  points  all  in  doubt,  and  the  embryo  at 
this  period  awaits  a  dominant  force  to  determine  its  sex. 

The  cases  of  true  hermaphroditism  are  divided  into :  bilateral, 
with  an  ovary  and  testicle  on  both  sides;  unilateral,  in  which 
there  is  an  ovary  and  testicle  on  one  side  with  either  an  ovary 
or  testicle  on  the  other;  and  lateral,  where  an  ovary  is  present 
on  one  side  and  a  testicle  on  the  other. 

Pseudohermaphroditism  is  caused  by  anomalies  in  develop- 
ment of  the  female  external  genitalia  already  described,  or  by 
malformations  of  the  penis  and  scrotum  in  the  male,  whence 
doubt  as  to  sex  arises. 

DISEASES  OF  THE  EXTERNAL  GENITALIA. 

VULVITIS. 

Definition. — An  acute  or  chronic  inflammation  of  the 
external  genitalia,  either  specific  or  non-specific  in  char- 
acter. 


38  THE  EXTERNAL  GENITALIA 

Pathology. — In  the  acute  stage  the  mucous  membrane 
around  the  vaginal  orifice  is  red,  swollen,  and  painful.  The 
glands  of  Bartholin  and  the  periurethral  glands  often 
become  infected  and  suppurate.  The  sebaceous  glands  of 
the  labia  majora  are  also  at  times  affected — follicular  vulvitis. 
In  the  chronic  stage  secretion  is  abundant,  and  papillomata 
often  form  around  the  vaginal  opening.  Erysipelatous,  gan- 
grenous, and  diphtheritic  vulvitis  occur. 

Etiology. — Seventy-five  per  cent,  of  the  cases  are  caused  by 
gonorrhea  (Veit).  Other  causes  are  the  accumulation  and 
subsequent  decomposition  of  discharges  from  the  uterus  and 
vagina  in  endometritis  and  vaginitis.  Putrid  discharges  from 
neglected  pessaries  and  vaginal  tampons,  sloughings  from 
cancers  and  myomata  may  act  as  exciting  causes,  and  con- 
tact with  ammoniacal  and  saccharine  urines  has  a  similar 
effect.  In  infants  the  condition  is  usually  due  to  want  of 
cleanliness  in  failing  to  remove  decomposing  urine  and  feces. 

Objective  Symptoms. — In  acute  vulvitis  the  external  genitalia 
are  swollen  and  edematous,  and  bathed  in  pus.  The  inguinal 
glands  and  glands  of  Bartholin  are  usually  somewhat  enlarged 
and  tender  when  the  disease  has  existed  for  any  length  of 
time.  In  the  gonorrheal  form  the  specific  microorganisms 
are  found  in  the  pus  during  the  early  stages  of  the  disease. 

Subjective  symptoms  are  a  feeling  of  heat  accompanied  by 
more  or  less  burning  and  itching.  Walking  causes  an  aggra- 
vation of  the  symptoms,  due  to  friction  of  the  inflamed  parts, 
and  micturition  further  increases  the  distress. 

In  gonorrheal  cases  the  disease  is  more  extensive,  involv- 
ing the  vagina,  urethra,  periurethral  glands,  and  glands  of 
Bartholin.  The  gland-infection  frequently  results  in  abscess 
formation. 

Diagnosis. — Vulvar  furunculosis  is  characterized  by  multiple 
small  abscesses  of  the  sebaceous  and  sweat  glands. 

Puerperal  vulvitis  is  the  result  of  uncleanliness  during  the 
puerperium,  the  lochial  discharge  being  allowed  to  accumu- 
late and  decompose  on  the  vulva.     The  diffuse  erythema 


VULVITIS  39 

arising  may  be  followed  by  ulceration,  which  is  generally 
superficial.  The  organism  most  commonly  present  is  the 
streptococcus. 

Syphilitic  vulvitis  may  occur  in  any  stage  of  the  syphilis. 
When  accompanying  the  chancre  in  the  primary  stage 
the  vulvitis  is  slight,  but  in  the  secondary  stage,  where  the 
vulva  is  often  covered  with  moist  patches  and  condylomata, 
an  extensive  vulvitis  exists.  In  the  tertiary  stage  vulvitis  is 
rarely  present. 

Erysipelatous  vulvitis  may  result  from  a  primary  infection 
of  the  vulva,  and  is  occasionally  seen  in  the  newborn. 

Tuberculous  vulvitis  is  of  rare  occurrence.  It  is  characterized 
by  irregular  ulcerations  on  the  external  genitals. 

Diphtheritic  vulvitis  is  occasionally  seen,  the  ulcerated 
surfaces  being  covered  by  a  pathogenic  false  membrane. 

Actinomycosis  involving  the  labia  majora  has  been  observed; 
two  cases  are  recorded. 

Treatment. — In  the  acute  form  the  patient  should  be  put  to 
bed,  a  wet  antiseptic  dressing  applied  to  the  vulva  and  kept 
constantly  moist.  If  there  is  much  pain  the  solution  should 
be  sedative. 

I^ — ?luinbi  acetatis .      .      .      ^  5J 

Tincturae  opii     ..,.,.,...  §S3 

AquEB »       q.  s.  ad  5vj- — M. 

Sig. — External  use. 

In  the  chronic  form  the  vulva  should  be  shaved,  thoroughly 
cleansed,  and  a  mild  ointment  applied  daily  thereafter,  such  as 

I^ — Acidi  salicylici gr.  xx 

Zinci  oxidi 5ij  , 

Petrolati q.  s.  ad     5j. 

M.  et  ft.  ungt. 

Sig. — External  use. 

When  the  vulvitis  is  due  to  the  irritation  of  discharges 
which  cannot  be  checked,  such  as  from  inoperable  carcinoma 
and  urinary  fistula,  much  may  be  accomplished  in  a  pallia- 


40  THE  EXTERNAL  GENITALIA 

tive  way  by  thorough  cleansing  of  the  surfaces  and  the  apph- 
cation  of  zinc  ointment  as  a  protective. 

Condylomata,  when  an  exciting  cause,  should  be  removed 
before  any  attempt  is  made  to  treat  the  vulvitis.  This  is  best 
accomplished  by  the  scissors  under  a  general  anesthetic,  and 
the  resulting  raw  surfaces  brushed  with  the  actual  cautery, 
or  pure  carbolic  acid. 


PRURITUS  VULVJE. 

Definition. — Pruritus  vulvae  should  be  perhaps  more  prop- 
erly considered  as  a  symptom  than  as  a  pathological  condi- 
tion. It  is  characterized  by  an  intense  itching  of  the  vulva, 
with  more  or  less  swelling  of  the  parts  and  extreme  nervous 
irritability. 

Etiology. — Doubtful,  believed  to  be  due  to  local  inflamma- 
tory changes  in  the  vulvar  corium  and  considered  by  some  as 
a  pure  neurosis. 

Pathology. — The  changes  in  the  skin  producing  pruritus 
vulvae  have  not  been  as  yet  accurately  determined.  The 
region  of  irritability  is  usually  the  upper  angle  of  the  labia 
majora  and  mons  veneris.  The  skin  is  inflamed,  thickened, 
and  excoriated  from  continual  scratching. 

Subjective  Symptoms. — An  intense  and  at  times  almost 
unbearable  burning  and  itching  about  the  vulva,  beginning 
most  often  around  the  clitoris,  paroxysmal  in  character,  and 
aggravated  by  warmth  and  motion. 

Objective  Symptoms. — The  skin  is  somewhat  thickened  in 
the  more  or  less  chronic  cases,  and  appears  dull  and  dry,  and 
is  covered  with  small  fissures  and  scratches,  the  result  of 
mechanical  irritation  by  the  patient  in  her  endeavors  to  relieve 
her  suffering. 

Diagnosis. — Inspect  carefully  the  vulva  for  any  irritating 
skin  eruption,  and  make  microscopic  examinations  of  the 
scrapings  for  parasites.     The  urine  should  be  examined  for 


KRAUROSIS  VULV.^  41 

sugar,  and  the  vagina  and  cervix  for  the  presence  of  irritating 
leucorrhea. 

Systemic  Treatment. — General  tonic  treatment  should  be 
given  in  all  cases.  Diabetes,  gout,  rheumatism,  masturba- 
tion, irritating  discharges  from  the  vagina  or  rectum,  and  in 
children  worms  and  highly  acid  urine  should  receive  appro- 
priate treatment.  Internally  the  bromides  and  arsenic  are 
often  of  value. 

The  local  treatment  is  usually  that  of  chronic  vulvitis. 
Strong  solutions  of  bichloride  of  mercury,  nitrate  of  silver  or 
tincture  of  iodine  often  relieve  the  itching,  and  cocaine  oint- 
ment gives  temporary  relief.  When  the  condition  persists 
after  the  removal  of  a  definite  cause,  and  in  spite  of  continuous 
careful  treatment,  the  division  and  resection  of  a  portion  of 
the  nerve  or  nerves  supplying  the  affected  areas,  as  recom- 
mended by  Hirst,  is  often  of  value. 


KRAUROSIS  VULV^. 

Definition. — Progressive  atrophy  and  shrinking  of  the 
tissues  of  the  vulva. 

Etiology. — Obscure.     Probably  a  trophic  disturbance. 

Pathology. — A  rare  condition  first  described  by  Breisky  in 
1885,  and  characterized  by  an  atrophic  shrinking  of  the  skin 
of  the  vulva  and  perineum.  The  surface  of  the  skin  is  dry, 
shining,  and  whitish  in  appearance.  It  is  so  exceedingly 
brittle  that  extensive  fissuring  often  follows  the  slightest 
manipulations.  The  sebaceous  and  sweat  glands  are  dimin- 
ished in  number,  and  painful  vascular  patches  develop  early 
around  the  vaginal  orifice. 

Symptoms. — Burning  and  itching  of  the  vulva,  with  extreme 
tenderness  in  the  early  stages.  The  contact  of  urine  on 
micturition  causes  pain  and  smarting.  Coitus  becomes 
difficult  or  impossible  on  account  of  the  pain  and  injury  it 
causes. 


42  THE  EXTERNAL  GENITALIA 

Diagnosis. — Usually  easy  in  advanced  cases.  In  the  early 
stages  the  symptoms  may  be  slight  or  entirely  absent.  Krau- 
rosis should  not  be  confused  with  pruritus  vulvae. 

Treatment. — Palliative  measures  are  unsatisfactory.  The 
symptoms  may  be  at  times  relieved  by  the  application  of  pure 
carbolic  acid,  and  the  fissures  touched  with  silver  nitrate 
stick.  Cocaine  is  of  little  service.  In  order  to  effect  a  cure 
complete  operative  removal  of  the  diseased  tissues  must  be 
practised. 

VENEREAL  ULCERS  AND  DISEASES. 

The  venereal  ulcers  and  the  venereal  diseases  are  not  peculiar 
to  women  and  do  not  call  for  special  consideration  in  a  work 

Fig.  11 


Papilloma  of  the  vulva. 


on  gynecology.     Of  the  so-called  venereal  warts,  however, 
the  condylomata  acuminata  deserve  special  mention  (Fig.  11). 


HEMATOMA  OF  THE  VULVA  43 

Condylomata  Acuminata. 

Definition. — A  hypertrophic  inflammatory  papillomatous 
lesion. 

Etiology. — Almost  invariably  of  gonorrheal  origin. 

Pathology. — Numerous  warty  outgrowths,  becoming  con- 
fluent, are  distributed  over  the  vulva,  perineum,  and  buttocks, 
often  reaching  up  into  the  vagina.  The  lesion  is  essentially 
an  overgrowth  of  the  papillae. 

Symptoms. — Besides  the  presence  of  the  growth,  which 
often  reaches  large  size,  the  symptoms  are  those  of  the  accom- 
panying vulvitis  to  which  the  irritating  discharge  from  the 
condylomata  generally  gives  rise. 

Diagnosis. — These  warts  are  easily  recognized.  Beginning 
as  pale,  red  growths,  their  color  later  turns  to  gray.  Rapid 
growth  during  pregnancy  is  the  rule. 

The  treatment  should  consist  in  operative  removal.  Small 
condylomata  may  be  burned  off  with  the  actual  cautery. 
Large  ones  should  be  removed  with  the  scissors  or  knife 
under  a  general  or  local  anesthetic. 

HEMATOMA  OF  THE  VULVA. 

Definition. — An  accumulation  of  blood  in  the  loose  cellular 
tissue  of  the  vulva. 

Etiology. — Spontaneous  rupture  of  an  overdistended  vein 
in  pregnancy  or  during  labor  is  the  most  frequent  cause. 
At  times  the  rupture  may  be  of  traumatic  origin,  the  result 
of  a  blow  or  fall. 

Pathology. — The  hemorrhage  is  always  venous  and  comes 
most  often  from  the  rupture  of  a  dilated  vein.  Copious 
bleeding  occurs,  readily  favored  by  the  loose  cellular  tissue 
of  the  vulva,  so  that  the  tumor  is  of  rapid  growth  and  often 
reaches  considerable  size.  Gradual  absorption  is  the  rule  in 
small  hematomata.    The  larger  ones  frequently  suppurate. 


44  THE  EXTERNAL  GENITALIA 

Symptoms. — A  hard,  elastic  tumor  develops  suddenly  in  the 
labium,  accompanied  by  tension  and  by  extreme  tenderness 
on  pressure  when  of  traumatic  origin.  There  is  often  a  feeling 
of  faintness  and  a  desire  to  urinate. 

Diagnosis. — The  tumor  is  easily  recognized  as  an  elastic 
swelling  showing  its  characteristic  deep  purple  color  through 
the  skin.  The  history  is  always  one  of  sudden  onset.  It  is 
important  to  distinguish  hematoma  from  vulvar  hernia. 

Treatment. — Rest  in  bed  and  cold  applications  to  the  part, 
preferably  ice.  Absorption  usually  takes  place  in  a  few  days, 
but  should  this  not  occur  and  suppuration  intervene,  free 
incision  with  subsequent  drainage  should  be  carried  out. 
Early  aspiration  before  the  blood  has  clotted,  with  subsequent 
firm  pressure  for  several  days  is  good  treatment  for  the  large 
hematomata  where  absorption  seems  improbable. 

VARICOCELE  OF  THE  VULVA. 

Definition. — Enlarged,  distended  veins  in  the  vulva. 

Etiology. — Venous  obstruction  in  pregnancy  and  pressure 
from  abdominal  and  pelvic  tumors. 

Pathology. — The  enlarged  veins  may  be  symmetrical  and 
involve  both  labia,  or  be  present  in  isolated  patches  only. 
Occasionally  the  condition  reaches  to  the  rectum  and  vagina. 

Symptoms. — A  feeling  of  weight  and  distention  in  the  labia, 
often  attended  with  burning  and  itching. 

Diagnosis. — The  enlarged  veins  are  easily  seen. 

Treatment. — Only  the  worst  cases  are  benefited  much  by 
treatment.  This  should  consist  of  rest  in  bed,  the  free  ad- 
ministration of  a  saline  cathartic,  and  when  rupture  seems 
imminent,  compression  of  the  dilated  veins  by  means  of  a 
T-bandage.  When  rupture  of  the  vein  occurs,  the  hemor- 
rhage is  usually  into  the  cellular  tissue  of  the  vulva,  forming  a 
hematoma.  In  superficial  veins  that  rupture  externally,  the 
bleeding  is  often  severe  and  should  be  controlled  by  firm 
pressure,  or  if  necessary  by  clamp  and  ligature. 


CYSTS  OF  THE  VULVA  45 


CYSTS  OF  THE  VULVA. 

Type. — The  most  common  form  of  cyst  met  with  in  the 
region  of  the  vulva  is  that  of  the  duct  of  BarthoKn's  gland, 
situated  in  the  labia  majora.  Cysts  of  the  labia  minora  are 
very  seldom  seen. 

Definition. — A  localized  swelling  in  the  lower  third  of  the 
labia  majora. 

Etiology. — The  obliteration  of  the  orifice  of  the  duct  which 
causes  the  retention  is  nearly  always  the  result  of  previous 
gonorrhea.  Accidental  ligation  of  the  duct  during  operations 
on  the  perineum  is  an  occasional  cause. 

Pathology. — Generally  a  retention  cyst  of  the  duct,  the 
gland  being  rarely  affected.  The  cyst  wall  is  quite  thin  and 
contains  a  thin,  viscid  mucus.  When  the  cyst  arises  in  the 
gland  the  swelling  is  more  deeply  situated.  These  cysts  are 
liable  to  attacks  of  acute  inflammation,  and  often  suppurate, 
forming  an  exceedingly  painful  abscess. 

Symptoms. — None  other  than  from  the  size  of  the  swelling, 
unless  inflammation  occurs.  There  is  then  acute  localized 
pain,  marked  tenderness  on  pressure,  and  often  high  fever, 
reaching  its  maximum  as  suppuration  begins. 

Diagnosis. — A  hard,  tense,  localized  enlargement  in  the 
labium  majus.  Tender  to  pressure  when  acute  inflam- 
mation is  present.  When  an  abscess  forms,  considerable 
induration  and  thickening  occur  and  the  pain  becomes 
intense. 

Treatment. — When  sufficient  size  is  attained  to  cause  con- 
stant annoyance,  or  to  interfere  with  coitus,  the  cyst  should  be 
removed.  This  is  best  accomplished  by  a  thorough  dissection, 
for  if  any  part  of  the  cyst  wall  remains,  recurrence  is  apt  to 
result.  For  inflammation  of  the  cyst,  rest  in  bed  and  cold 
applications  are  indicated.  When  an  abscess  forms,  free 
incision  and  drainage  should  be  resorted  to.  When  complete 
removal  of  the  cyst  wall  by  dissection  is  diflficult,  on  account 


46  THE  EXTERNAL  GENITALIA 

of  adhesions,  it  is  best  to  thoroughly  destroy  its  secreting  sur- 
face by  the  apphcation  of  pure  carbohc  acid  with  subsequent 
gauze  drainage. 


ELEPHANTIASIS  OF  THE  VULVA. 

Definition. — A  hyperplasia  of  the  skin  and  subcutaneous 
cellular  tissue  rarely  seen  in  western  countries. 

Etiology. — Uncertain;  an  endemic  form  in  certain  countries 
points  to  infection. 

Pathology. — Three  forms  exist  (Cornil  and  Ranvier).  In 
the  first  the  entire  derma  is  hypertrophied;  in  the  second 
the  engorgement  of  the  tissues  extends  over  a  circumscribed 
area  only;  and  in  the  third  the  thickening  of  the  skin  is 
enormous  and  involves  all  its  structure.  In  all  three  the 
characteristic  lesion  is  a  dilatation  of  the  lymphatics. 

Symptoms. — Discomfort  and  inconvenience  caused  by  the 
increase  in  the  size  of  the  labia.  Edema  and  friction  ulcers 
often  develop. 

Diagnosis. — The  labia  majora  enormously  hypertrophied, 
and  frequently  hanging  down  as  far  as  the  knees,  are  the 
chief  diagnostic  feature. 

Treatment. — Total  removal  of  the  diseased  structures  by 
operation.  Special  care  should  be  taken  to  guard  against 
excessive  hemorrhage  at  the  time. 


BENIGN  TUMORS  OF  THE  VULVA. 

Type. — Newgrowths  of  the  vulva  are  of  extreme  rarity;  the 
fibromata  are  the  variety  most  often  seen. 

Etiology. — Uncertain;  the  fibromata  probably  originate 
from  the  round  ligament  in  the  canal  of  Nuck. 

Pathology. — The  fibromata  spring  from  the  connective 
tissue  of  the  labia.    They  are  of  slow  growth,  hard,  rounded. 


MALIGNANT  TUMORS  OF  THE  VULVA  47 

and  circumscribed,  and  composed  of  connective  tissue  inter- 
mixed with  muscle  fiber.  The  lipomata  arise  from  the  sub- 
cutaneous fat  on  the  mons  veneris.  Sebaceous  cysts  are 
occasionally  seen  on  the  labia. 

Symptoms. — These  are  mechanical  from  the  presence  of  the 
tumor. 

Diagnosis. — The  fibromata  are  recognized  by  their  hard, 
firm  consistency;  the  lipomata  are  soft.  Both  appear  as 
circumscribed  globular  swellings  covered  by  non-adherent 
integument  and  are  not  painful  to  pressure,  nor  is  there  any 
impulse  on  coughing.  The  sebaceous  cysts  are  small  semi- 
transparent  elevations  filled  with  sebaceous  material. 

Treatment. — The  liability  of  the  fibromata  to  undergo 
sarcomatous  changes  calls  for  operative  removal.  The 
lipomata  need  special  treatment  only  from  their  size.  The 
sebaceous  cysts  frequently  become  inflamed  and  suppurate, 
necessitating  removal. 


MALIGNANT  TUMORS  OF  THE  VULVA. 

Varieties. — Sarcomata  and  carcinomata. 

Etiology. — The  same  as  in  cancer  elsewhere. 

Pathology. — The  vulva,  of  all  regions  of  the  female  genital 
tract,  is  the  one  least  often  attacked  by  carcinoma.  Schuary 
found  it  only  thirty  times  in  1147  cases.  The  disease  begins 
most  frequently  in  the  clitoris  or  in  the  groove  between  the 
labia,  first  appearing  as  a  small  nodule,  which  rapidly  goes 
on  to  ulceration.  Quick  growth  with  infiltration  of  the  sur- 
rounding tissues  and  early  involvement  of  the  inguinal  and 
femoral  glands  is  characteristic. 

Symptoms. — Pain  appears  early  in  the  disease  and  is  a  con- 
stant symptom.  Rapid  growth  with  superficial  or  diffuse 
infiltration  of  the  neighboring  tissues  and  a  constant  foul  dis- 
charge from  the  ulcerating  surface  completes  the  clinical 
picture.    In  the  later  stages  the  emaciation  is  marked. 


48  THE  EXTERNAL  GENITALIA 

Diagnosis. — Age  is  of  importance,  as  is  also  the  effect  on  the 
genital  system.  The  growth  ulcerates  early  and  involvement 
of  the  vaginal  glands  is  usually  found.  The  microscope  is 
necessary  for  a  positive  diagnosis. 

Treatment. — Early  removal  of  the  growth,  together  with  the 
inguinal  and  femoral  glands  of  the  same  side,  should  be 
practised.  In  the  later  stages  operation  is  contra-indicated 
and  palliative  measures  only  should  be  employed. 

Prognosis. — ^The  prognosis,  except  in  very  early  cases,  is 
unfavorable. 

Sarcomata  of  the  vulva  are  of  rare  occurrence,  the  melanotic 
variety  being  relatively  frequent.  Recurrence  is  almost  cer- 
tain, though  early  operation  is  advisable. 


VULVAR  HERNIA. 

Definition. — A  protrusion  of  the  intestines,  omentum,  or 
both,  into  the  labia  majora. 

Etiology. — The  same  as  hernia  in  general. 

Pathology. — The  escaped  viscera  descend  by  the  side  of,  or 
in,  the  processus  vaginalis  of  Nuck  and  enter  the  labium  by 
the  inguinal  canal.  A  variety  known  as  ^perineal  may  occur 
when  the  viscera  pass  down  by  the  side  of  the  vagina  into  the 
labium. 

Symptoms. — More  or  less  constant  pain  in  the  region  of  the 
swelling,  especially  on  exertion.  Acute  pain  with  gastro- 
intestinal symptoms  if  strangulation  occurs. 

Diagnosis. — A  painful  swelling  of  varying  size  situated  in 
the  labium  majus  is  found.  Important  to  make  a  differential 
diagnosis  from  tumor  of  the  labium,  or  cyst  of  Bartholin's 
gland. 

Hernia.  Cyst  or  Tumor. 

Soft  or  elastic.  Firm  or  hard. 

Size  increases  on  coughing.  Unchanged  on  coughing. 

Tends  to  disappear  on  pressure.  Unchanged  by  pressure. 


MALFORMATIONS  OF  THE  VAGINA  49 

Treatment. — Reduction  by  gentle  taxis  when  possible  and 
retention  by  truss.  When  irreducible  or  strangulated,  opera- 
tion becomes  necessary. 


CHAPTER  V. 

THE  VAGINA. 

MALFORMATIONS  OF  THE  VAGINA. 

As  the  vagina  has  its  development  in  part  from  the  ducts  of 
Mliller,  various  errors  in  formation  are  found  analogous  to 
those  occurring  in  the  uterus  and  tubes.  A  complete  absence 
or  imperfect  development  may  exist,  and  where  the  Miillerian 
ducts  fail  to  coalesce,  a  double  vagina  results.  If  coalescence 
without  absorption  takes  place,  a  septum,  partial  or  complete, 
dividing  the  vagina  into  two  passages,  is  left. 

Absence  of  the  vagina  results  from  a  failure  in  the  develop- 
ment on  the  part  of  the  Miillerian  ducts.  When  the  entire 
Miillerian  tract  fails  to  develop  there  is  a  corresponding 
absence  of  vagina,  uterus,  and  tubes. 

Atresia  of  the  vagina  is  usually  incomplete,  the  lower  seg- 
ment being  closed.  Behind  the  obstruction  there  is  an  accu- 
mulation of  blood  from  successive  menstruations,  which  when 
in  the  vagina  alone  is  known  as  hematocolpos,  when  in  the 
uterus,  hematemetra,  and  when  in  the  tubes,  hematosalpinx. 
The  retained  blood  seldom  coagulates. 

Double  vagina  is  due  to  imperfect  fusion  of  the  ducts  of 
Miiller,  and  the  two  oanals  lie  side  by  side. 

Hour-glass  contraction  of  the  vagina  results  from  an  im- 
proper fusion  of  the  upper  and  middle  third  of  the  vagina, 
and  is  frequently  seen  in  cases  of  anteflexion  of  the  uterus. 
The  constriction  may  be  so  marked  that  the  cervix  cannot  be 
seen  or  examined  through  it. 
4 


50 


THE  VAGINA 


ATRESIA  OF  THE  GENITAL  CANAL. 

Definition. — Atresia  of  the  genital  canal  is  an  occlusion  of 
the  genital  tract  usually  accompanied  by  accumulation  of  the 
menstrual  blood.  The  obstruction  may  be  at  one  of  three 
places — the  hymen,  the  vagina,  or  the  cervix. 

Fig.   12 


Atresia  of  the  vaginal  outlet;  hematocoipos. 


Etiology. — Atresia  may  be  either  congenital  or  acquired. 
The  former  is  due  to  non-development  or  closure  during 
fetal  life.  The  acquired  form  may  be  produced  by  inflamma- 
tion of  the  mucous  membranes  and  subsequent  adhesions  of 


ATRESIA  OF  THE  GENITAL  CANAL 


51 


the  opposed  surfaces,  or  cicatrization  following  injuries 
received  in  childhood,  or  during  labor.  Atresia  may  follow 
sloughing  after  the  caustic  effect  of  very  strong  douches. 

The  most  usual  form  of  atresia  met  with  is  congenital,  due 
to  imperforate  hymen. 


Fig 


Atresia  of  the  lower  third  of  the  vagina. 


Pathology. — Atresia  Hymenalis. — The  hymen  exists  as  a 
continuous  membrane,  tougher  than  normal  and  quite  thick. 
The  accumulation  of  menstrual  blood  distends  the  vagina, 
forming  a  tense  fluctuating  mass  that  at  times  fills  the  whole 
pelvis,  even  reaching  well  up  into  the  abdominal  cavity.  The 
uterus  either  lies  on  top  of  the  mass,  or  after  the  cervix  dilates 
becomes  itself  distended  with  blood.    In  atresia  vaginalis  the 


52 


THE  VAGINA 


seat  of  the  obstruction  is  most  often  in  the  lower  third  of  the 
vagina,  though  the  atresia  may  exist  at  more  than  one  point. 
In  atresia  cervicalis  the  obstruction,  usually  slight,  exists  most 
often  at  the  internal  os. 


Fig.   14 


Atresia  of  the  vaginal  outlet :  hematocolpos  and  hematometra. 


The  retained  blood  is  of  a  dark  chocolate  color,  thick  in 
consistence,  and  is  free  from  coagula.  It  contains  shrunken 
red  blood  cells,  fiat  epithelial  cells,  blood  pigment,  and  debris. 

Symptoms  do  not  arise  until  puberty,  and  consist  of  men- 
strual molimina  unaccompanied  by  the  appearance  of  the 
menstrual  discharge.  As  the  distention  increases  transitory 
pain  develops,  later  becoming  continuous.     The  abdomen 


ATRESIA  OF  THE  GENITAL  CANAL 


53 


enlarges  and  pregnancy  may  be  suspected  on  account  of  the 
existing  amenorrhea.  Unless  relieved  by  operation  the  con- 
dition usually  terminates  fatally  through  rupture  of  the  uterus 
or  cervix,  or  through  peritonitis  arising  independent  of 
rupture. 

Fig.  15 


Atresia  of  the  lower  two-thirds  of  the  vagina:  hematocolpos  and  hematometra 

above  atresia. 


Diagnosis. — In  general  by  vulvovaginal  examination  little 
difficulty  will  be  experienced  in  arriving  at  a  correct  diagnosis. 

In  obstruction  at  the  hymen  its  imperforate  condition  is 
readily  detected  and  rectal  examination  shows  a  tense, 
elastic  tumor  filling  the  vagina.     By  abdominal  examination 


54  i'fi^  VAGINA 

this  may  be  felt  at  the  pelvic  brim,  or  even  up  as  high  as  the 
umbilicus.  The  uterus  may  be  mapped  out  as  a  small,  hard 
tumor  on  the  summit  of  the  mass. 

In  atresia  of  the  vagina  the  hymen  does  not  bulge;  the  other 
conditions  will  be  found  practically  the  same. 

In  atresia  of  the  cervix  difficulty  in  distinguishing  from  early 
pregnancy  may  arise.  On  careful  examination,  however,  the 
condition  of  the  cervix,  the  shape  of  the  uterus,  and  the  char- 
acteristic tense  feel  of  the  tumor,  together  with  the  history 
of  the  case,  should  establish  a  differential  diagnosis  (Figs.  12 
to  15). 

Treatment  should  be  operative  and  carried  out  as  soon  as  the 
diagnosis  is  certain.  An  incision  through  the  obstruction  to 
the  retained  fluid  should  be  made,  and  gradual  evacuation 
accomplished. 

The  operation  is  not  free  from  danger,  and  should  be  per- 
formed under  a  general  anesthetic  in  a  hospital  or  at  the 
patient's  house — never  in  the  'physician  s  office.  Too  rapid 
collapse  of  the  sac  may  cause  the  rupture  of  a  distended 
Fallopian  tube,  or  of  vascular  adhesions  in  the  pelvis,  and  be 
followed  by  a  fatal  hemorrhage  unless  immediate  laparotomy 
is  performed  and  the  bleeding  vessels  tied. 


DISEASES  OF  THE  VAGINA. 

VAGINITIS. 

Definition. — Vaginitis  is  an  inflammation  of  the  mucous 
membrane  lining  the  vagina. 

Pathology. — There  are  increased  vascularity  and  redness  of 
the  mucosa,  the  epithelium  is  swollen,  the  rugae  are  exagger- 
ated, red,  and  easily  bleed.  The  deeper  vaginal  and  cellular 
tissues  are  involved  only  in  the  severest  types.  Exfoliation 
may  take  place,  leaving  raw  patches,  which  ultimately  cohere 
and  give  rise  to  atresia. 


VAGINITIS  55 

The  microorganisms  most  commonly  the  cause  are  the 
gonococcus,  Loeffler's  bacillus,  the  streptococcus  of  erysipe- 
las, the  staphylococcus,  and  fungi.  A  small  number  of  cases 
are  caused  by  mechanical  and  thermic  irritation  from  irri- 
tating pessaries  and  too  hot  or  too  concentrated  douches. 

Etiology. — Vaginitis  may  be  due  either  to  direct  invasion 
by  bacteria,  or  to  secondary  irritation  by  discharges  from  the 
uterus. 

Varieties  of  Vaginitis. 

Catarrhal,  or  simple,  vaginitis  is  the  most  usual  form.  It  is 
characterized  by  a  uniform  redness  of  the  mucosa,  with 
swelling  and  an  increase  in  the  vaginal  secretions. 

Granular  vaginitis,  an  advanced  stage  of  the  catarrhal  type, 
is  due  to  long-continued  or  repeated  attacks. 

Diphtheritic  vaginitis,  due  to  the  bacillus  of  diphtheria, 
occurs  either  in  localized  patches,  or  involves  the  whole 
vagina.  The  mucous  membrane  is  thickened  and  covered 
with  a  diphtheritic  membrane. 

Senile  vaginitis  comes  only  after  the  menopause,  and  pro- 
duces a  cicatricial  contraction  of  the  vagina.  Patches  of  the 
epithelium  are  shed,  thus  producing  raw  surfaces  that  fre- 
quently adhere  together. 

Gonorrheal  vaginitis  is  due  to  infection  by  the  gonococcus  of 
Neisser.  This  form  is  the  most  intractable  save  the  senile 
form,  and  may  persist  for  years  or  life.  Extension  of  the 
infection  to  the  uterus.  Fallopian  tubes,  and  peritoneal 
cavity,  producing  endometritis,  pyosalpinx,  and  localized 
peritonitis  is  more  common  than  many  physicians  realize. 

Symptoms. — Pelvic  pain;  frequent  micturition,  with  more  or 
less  smarting  and  burning;  a  sensation  of  heat  and  burning 
in  the  vagina;  and  a  copious  mucopurulent  discharge. 

These  symptoms  may  be  present  in  both  simple  and  gonor- 
rheal vaginitis,  but  in  the  latter  the  urinary  disturbances  are 
more  marked.     The  symptoms,  particularly  in  gonorrhea  of 


56  THE  VAGINA 

the  vagina,  date  from  a  distinct  onset,  are  of  longer  duration, 
yielding  less  readily  to  treatment,  and  complications,  such  as 
enlargement  of  the  inguinal  and  vulvovaginal  glands,  endo- 
metritis, salpingitis  or  cystitis,  often  make  their  appearance 
earlv. 

t/ 

Diagnosis. — Inspection  shows  a  mucopurulent  discharge 
contained  in  or  escaping  from  a  much  reddened  and  inflamed 
vagina.  The  mucous  membrane  is  swollen,  eroded  in  patches, 
and  extremely  tender  and  bathed  in  pus.  In  the  gonorrheal 
type  the  orifices  of  the  ducts  to  the  vulvovaginal  and  peri- 
urethral glands  will  be  seen  to  be  red  and  inflamed.  A 
differential  diagnosis  between  simple  and  gonorrheal  vaginitis 
may  only  be  made  with  certainty  when  the  gonococcus  is 
found  in  the  discharge.  In  every  case  of  purulent  vaginitis 
repeated  microscopic  examinations  of  the  pus  should  always 
be  made. 

Treatment. — In  acute  cases  rest  in  bed  and  prolonged  vaginal 
irrigation  three  times  a  day  with  a  1  to  1000  bichloride  solu- 
tion. Where  the  gonococcus  is  present  in  the  pus  the  vaginal 
walls,  cervix,  and  cervical  canal  should  be  dried  and  a  thor- 
ough application  of  a  20  per  cent,  silver  nitrate  or  50  per  cent, 
argyrol  solution  made  every  other  day.  This  is  best  done  with 
the  patient  in  the  knee-chest  position,  as  the  air  distention 
of  the  vagina  obliterates  the  rugse,  giving  a  smooth  surface 
for  the  local  application. 

In  the  chronic  cases  the  gonococci  are  most  frequently  found 
in  the  'posterior  fornix,  in  the  natural  pocket  just  behind  the 
posterior  cervical  lip.  It  is  here  that  the  application  of  silver 
nitrate  should  be  particularly  thorough. 

As  serious  complications  in  the  uterus  and  Fallopian  tubes 
result  from  direct  invasion  of  the  gonococci  every  effort 
should  be  made  early  in  the  disease  to  destroy  the  germs, 
while  they  are  still  limited  to  the  vagina  and  cervix.  Cessa- 
tion of  sexual  intercourse  is  imperative. 


TUMORS  OF  THE  VAGINA  57 


VAGINISMUS. 

Definition. — Vaginismus  is  a  painful  reflex  muscular  con- 
traction of  the  vaginal  orifice. 

Etiology. — Most  often  observed  in  patients  of  nervous  and 
sensitive  temperament,  and  is  the  result  of  an  inflamed, 
partially  ruptured  hymen,  or  small  ulcers  or  fissures  about  the 
fourchette,  fossa  navicularis,  or  anus.  Urethral  caruncle  is 
sometimes  a  cause. 

Symptoms. — Painful  or  difficult  sexual  intercourse  (dyspa- 
reunia).  The  suffering  is  at  times  so  great  as  to  drive  the 
patient  to  seek  medical  advice,  though  this  is  often  prevented 
by  a  sense  of  delicacy.  A  very  common  cause  of  dyspareunia, 
however,  is  some  pathological  lesion  in  the  pelvis,  as  a  pro- 
lapsed, adherent,  and  inflamed  ovary  or  pus  tube.  Relative 
sterility  is  often  a  symptom. 

Diagnosis. — In  some  cases  the  patient  wears  an  anxious, 
careworn  expression,  and  in  others  is  markedly  hysterical. 
Vaginal  examination  is  usually  painful  and  should  be  preceded 
by  a  careful  inspection  of  the  external  genitals  for  any  ulcers, 
fissures,  or  atresia.    Cocainization  may  aid  extreme  cases. 

Treatment. — Any  cause  of  local  irritation,  such  as  urethral 
caruncle,  should  be  removed.  A  thick  inflamed  hymen  should 
be  incised,  and  any  ulcer  or  fissure  about  the  vagina  or  rectum 
properly  treated.  When  no  local  lesion  may  be  discovered, 
forcible  dilatation  of  the  vaginal  orifice  under  an  anesthetic 
is  often  of  benefit.  Complete  rest  from  sexual  intercourse 
should  be  enjoined  during  treatment.  Tonics,  exercise,  and 
a  complete  change  of  scene  are  beneficial. 

TUMORS  OF  THE  VAGINA. 

The  more  common  varieties  of  tumor  of  the  vagina  are,  in  the 
order  named,  cysts,  fibromata,  carcinomata,  sarcomata,  and 
tuberculosis. 


58  THE  VAGINA 

Cysts  of  the  Vagina. — Occurrence  and  Pathology. — Cysts 
are  the  commonest  of  the  vaginal  tumors.  They-  are  most 
frequently  found  in  the  lower  third  of  the  anterior  vaginal 
wall.  Generally  single  and  lined  with  a  single  layer  of  cylin- 
drical epithelium.     Of  small  size,  rarely  larger  than  a  hen's 

egg- 

The  etiology  of  cysts  of  the  vagina  is  uncertain. 

Symptoms  are  seldom  present  except  in  cysts  large  enough 
to  cause  dyspareunia. 

Diagnosis  rests  on  the  recognition  of  smooth,  elastic  tumors 
situated  inside  the  vagina.  Cysts  of  the  vagina  should  not 
be  confounded  with  the  cysts  of  the  vulvovaginal  glands, 
which  are  outside  the  vagina  in  the  labia. 

Treatment. — Small  cysts  do  not  call  for  treatment.  Larger 
ones,  when  causing  symptoms,  should  be  removed  by  careful 
dissection. 

Fibroid  Tumors. — The  etiology  is  the  same  as  of  fibromata 
in  general. 

Pathology. — Fibroma  of  the  vagina  composed  chiefly  of 
fibrous  tissue  interlaced  with  unstriped  muscular  fibres. 
They  rarely  originate  in  the  vagina,  but  when  present  usually 
grow  from  the  anterior  vaginal  wall  by  a  well-developed 
pedicle. 

Symptoms  arise  only  when  the  tumor  is  of  large  enough 
size  to  interfere  with  micturition,  menstruation,  or  coitus. 

The  diagnosis  offers  little  difficulty  when  the  pedicle  may 
be  found  and  traced  to  its  origin.  The  tumor  is  hard,  firm, 
and  usually  rounded  in  form,  and  not  particularly  tender. 

Treatment. — Ligature  and  division  of  the  pedicle,  or,  when 
the  tumor  is  sessile,  enucleation. 

Carcinoma  of  the  Vagina. — Definition. — Carcinoma  of 
the  vagina  is  a  primary  malignant  involvement  of  the  vaginal 
wall. 

Pathology. — Primary  carcinoma  of  the  vagina  is  of  rare 
occurrence.  Two  forms  are  recognized,  a  diffuse  infiltration 
and  a  localized  papillary  infiltration.    Extension  into  the  para- 


TUMORS  OF  THE  VAGINA  59 

vaginal  tissues  is  rapid,  and  enlargement  of  the  vaginal  glands, 
due  to  carcinomatous  invasion,  generally  appears  sooner  or 
later. 

Etiology. — Most  common  between  the  ages  of  fifty  and  sixty 
Prolonged  irritation  from  a  foreign  body,  such  as  a  pessary, 
may  play  an  important  role. 

Symptoms. — Hemorrhage  and  a  fetid  discharge  from  the 
vagina.    In  the  early  stages  pain  is  slight  or  entirely  absent. 

Diagnosis. — Often  doubtful  on  account  of  the  difficulty  in 
securing  a  satisfactory  examination  of  the  cervix,  the  most 
common  seat  of  carcinoma  in  the  genital  tract. 

The  growth  rarely  reaches  -  large  size,  but  remains  as  an 
ulcer  having  an  uneven  base,  bleeding  freely  when  touched, 
and  covered  with  a  putrid  secretion.  Secondary  nodules  are 
often  seen  on  the  vagina  at  a  distance  from  the  principal 
lesion. 

Treatment. — Success  depends  on  an  early  diagnosis  and 
complete  operative  removal  of  the  diseased  tissue.  Total 
extirpation  of  the  vagina  may  be  called  for.  In  cases  beyond 
the  operative  stage  the  use  of  the  actual  cautery  is  recom- 
mended as  a  relief  for  the  sloughing  and  fetor. 

Sarcoma  of  the  Vagina. — Occurrence. — Sarcoma  of  the 
vagina  is  a  rare  condition.  It  may  occur  quite  early  in  life, 
one  case  where  it  was  apparently  congenital  being  recorded. 

The  symptoms  do  not  differ  materially  from  those  of  sar- 
coma of  the  uterus,  and  the  treatment  consists  in  early 
removal.    Recurrence  is  very  likely  to  take  place. 

Tuberculosis  of  the  Vagina. — Occurrence. — Primary  tuber- 
culosis of  the  vagina  is  of  extreme  rarity,  and  the  secondary 
form  only  of  importance.  This,  as  a  part  of  the  general 
affection,  calls  for  constitutional  rather  than  special  treatment. 


CHAPTER  VI. 

THE  UTERUS. 

MALFORMATIONS  OF  THE  UTERUS. 

The  varieties  of  uterine  malformation  most  commonly 
encountered  are:  Uterus  bipartitus,  unicornis,  didelphys, 
bicornis,  septus  and  infantilis. 

These  various  conditions  known  as  malformations  are  not 
such  in  a  real  sense,  but  arise  as  a  result  of  arrested  develop- 

FiG.  16 


Uterus  unicornis:  LH,  left  horn;  LT,  left  tube;  Lo,  left  ovary;  LLr,  left  round 
ligament;  RH,  right  horn;  RT,  right  tube;  Ro,  right  ovary;  RLr,  right  round 
ligament.     (From  Schroeder.) 

ment.  The  term,  as  generally  used,  means  an  incomplete 
result  rather  than  a  defective  process.  In  other  words,  a  lack 
of  development  and  not  a  maldevelopment.  In  general  terms, 
therefore,  two  causes  operating  together — arrested  develop- 
ment and  arrested  growth — are  responsible  for  these  results. 
Pathology. — Complete  absence  of  the  uterus  is  of  rare  occur- 
rence, but  a  rudimentary  uterus  consisting  of  a  few  fibers  with 
some  connective  tissue  is  occasionally  met  with. 
(60) 


MALFORMATIONS  OF  THE   UTERUS 


61 


Uterus  bipartitus  presents  rudimentary  horns  which  may, 
or  may  not,  be  patent.  The  ovaries  at  times  may  be  well 
developed.  The  external  genitals  and  the  breasts  may  be 
perfectly  formed. 

Uterus  unicornis  may  sometimes  have  an  accompanying 
rudimentary  second  horn.  The  vaginal  portion  of  the  cervix 
is  small,  the  body  of  the  uterus  is  of  disproportionate  length, 
the  fundus  small  and  tapering,  with  a  single  Fallopian  tube 
and  ovary  (Fig.  16). 

Fig.  17 


Uterus  didelphys:  a,  right  cavit_  .   ? .  I  f t  ty;  c,  right  OA^ary;  d,  right  round 

ligament;  e,  left  round  ligament;  f,  left  tube;  g,  left  vaginal  portion;  h,  right 
vaginal  portion;  i,  right  vagina;  j,  left  vagina;  k,  partition  between  the  two  vagina;. 
(From  De  Sinety,  after  Ollivier.) 

Uterus  didelphys  shows  two  uterine  halves  separate  through- 
out their  course.  The  vagina  may  be  double,  single,  or 
entirely  absent  (Fig.  17). 

Uterus  bicomis  consists  in  the  separation  into  two  horns, 
more  or  less  appreciable  externally,  according  to  the  degree  of 


62 


THE   UTERUS 


bifurcation  present.  This  may  be  only  a  mere  depression  at 
the  middle  of  the  fundus,  or  a  well-marked  separation  extend- 
ing down  as  low  as  the  internal  os  (Fig.  18). 


Fig.  18 


■f^vT" 


Uterus  bicornis  unicollis  of  a  virgin:  a,  vagina;   6,  single  neck;  c,  c,  horns;  d,  d, 
tubes;  e,  e,  ovaries;  /,  /,  round  ligaments.     (From  Kussmaul.) 

Uterus  septus  has  no  external  indication  of  the  division 
existing;  internally,  however,  the  uterine  cavity  is  divided  by 
a  septum  extending  from  the  fundus  downward,  at  times  as 
far  as  the  external  os  (Fig.  19). 

Uterus  infantilis  is  as  a  uterus  much  smaller  than  normal 
and  there  is  a  persistence  of  the  relative  proportion  between 
body  and  cervix  normal  up  to  the  time  of  puberty.  The  body 
is  small  and  short  and  the  cervix  disproportionately  long,  and 
a  marked  angle  of  flexion  exists  between  the  two  (Fig.  20.) 

Etiology. — The  malformations  vary  according  to  the  period 
at  which  the  arrest  in  development  and  growth  occurs.  From 
the  first  to  the  third  month  the  septum  between  the  ducts  of 
Miiller  is  undivided.  By  the  end  of  the  third  month  this 
septum  has  entirely  disappeared,  and  the  upper  portions  of 


MALFORMATIONS  OF  THE   UTERUS 


63 


the  ducts  remain  separate,  forming  the  uterine  cornua  and  the 
Fallopian  tubes.     During  the  fourth  and  fifth  months  the 


Fig.  19 


Uterus  septus  duplex  (natural  size),  completely  double  uterus,  and  incompletely 
double  vagina  of  a  girl  aged  twenty-two  years:  a,  a,  tubes;  &,  h,  fundus  of  the  double 
uterus;  c,  c,  c,  partition  of  uterus;  d,  d,  cavities  of  the  uterine  bodies;  e,  e,  internal 
orifices;  /,  f,  external  walls  of  the  two  necks;  g,  g,  external  orifices;  h,  h,  vaginal 
canals;  i,  partition  which  divided  the  upper  third  of  the  vagina  into  two  halves. 
(From  Kussmaul.) 


angle  between  the  cornua  disappears,  and  in  the  last  five 
months  that  portion  of  the  fundus  between  the  Fallopian 


64 


THE   UTERUS 


Fig.  20 


Infantile  uterus. 
(Schroeder.) 


tubes  becomes  arched.  From  birth  to  puberty  no  important 
change  takes  place,  but  at  puberty  further  development 
occurs,  the  fundus  enlarges,  the  angle  of  flexion  between  the 
cervix  and  fundus  disappears,  and  the  uterus 
passes  from  the  infantile  to  the  virgin  form, 
the  change  being  complete  at  about  the 
thirteenth  year. 

Symptoms  are  due  to  an  impairment  of 
function  and  do  not  appear  until  puberty  is 
reached. 

There  may  be  nothing  in  the  external 
appearance  of  the  patient  to  point  toward 
the  pathological  condition  present.  Figure, 
features,  and  voice  may  be  all  of  the  feminine 
type,  and  the  mammse  and  external  genitals 
fully  developed. 

The  non-appearance  of  menstruation  may 
be    the    only    suggestive    symptom.     In    the 
uterus  unicornis,  menstruation,  conception,  and  pregnancy 
may  take  place  undisturbed  in  the  developed  horn. 

In  cases  of  double  uterus  menstruation  from  the  second 
uterine  cavity  may  occur  regularly  throughout  pregnancy. 
The  symptoms  observed  in  the  infantile  and  congenitally 
atrophic  types  are :  absent  or  scanty  menstruation,  dysmenor- 
rhea, and  the  various  constitutional  nervous  disturbances 
usually  associated  with  these  conditions. 

Diagnosis. — Complete  absence  of  the  uterus  cannot  be 
determined  with  certainty  during  life  except  by  operation. 
A  rudimentary  condition  may  remain  undiagnosticated  even 
after  careful  examination.  The  uterus  unicornis  and  uterus 
didelphys  are  rare  and  seldom  diagnosticated.  The  uterus 
bicornis  is  more  frequently  met  with,  and  when  well  marked 
is  easily  recognized.  The  uterus  septus  is  easily  detected  if 
the  septum  extends  downward  as  far  as  the  external  os. 

When  doubt  exists,  and  it  is  of  importance  to  determine 
the  exact   condition  present,  a   thorough  instrumental  and 


ATROPHY  OF  THE  CERVIX  AND   UTERUS  65 

digital  examination  under  a  general  anesthetic  should  be 
made. 

Treatment. — The  malformations  of  the  uterus,  as  a  rule, 
do  not  call  for  operative  treatment,  except  in  the  presence  of 
marked  interference  with  the  normal  functions  of  that  organ. 

In  the  infantile  and  congenitally  atrophic  types  much  may 
be  done  toward  stimulating  further  growth  and  development, 
if  the  case  is  taken  in  time.  A  thorough  divulsion  of  the  cervix 
and  firm  packing  of  the  uterine  cavity  with  gauze,  repeated  at 
three-month  intervals,  will  often  produce  very  beneficial 
results  and  should  always  be  given  a  fair  trial.  Plenty  of 
outdoor  exercise  and  good  nutritious  food  are  of  great  im- 
portance in  the  treatment. 


MALFORMATIONS  OF  THE  CERVIX  UTERI. 

Small  External  Os. — In  this  condition,  undoubtedly  of 
congenital  origin,  the  external  os  is  much  smaller  than  normal, 
at  times  having  hardly  more  than  the  so-called  pin-hole 
opening.  The  cervix  is  long  and  conical  in  shape  and  of  firm 
consistency,  due  to  increase  of  its  connective  tissue.  Rigidity 
of  the  cervix  is  commonly  associated  with  this  condition,  as 
well  as  stenosis  of  the  internal  os. 

Atresia  of  the  Cervix. — Occlusion  of  the  canal  is  rare  as  a 
congenital  condition,  but  is  more  frequently  seen  in  patients 
well  past  the  menopause.  It  is  at  times  acquired  after  ampu- 
tation of  the  cervix  and  after  long-continued  application  of 
caustics  to  the  cervical  canal.     (See  chapter  on  Atresia.) 


ATROPHY  OF  THE  CERVIX  AND  UTERUS. 

Occurrence. — Atrophy  of  the  cervix  and  uterus  are  met  with 
under  varying  conditions.     It  may  be  either  congenital  or 
acquired.     It  is  seen  associated  with  certain  constitutional 
5 


66  THE  UTERUS 

affections,  such  as  phthisis  and  chlorosis,  and  in  acute  general 
affections,  such  as^scarlet  and  typhus  fever.  It  may  result 
from  superinvolution  in  the  puerperium,  and  is  normal  in  the 
senile  uterus  after  the  menopause. 

Symptoms  and  Diagnosis. — There  will  be  found  by  vaginal 
examination  a  small,  flat  cervix  projecting  only  slightly  into 
the  vagina,  and  upon  making  the  bimanual  examination  the 
uterus,  much  smaller  than  normal,  is  recognized  with  difficulty. 
To  determine  the  causes  responsible  for  the  condition  found 
necessitate  a  careful  consideration  of  the  patient's  history. 
Amenorrhea,  or  scanty  menstruation,  and  delayed  puberty 
point  to  a  congenital  condition  of  imperfect  development. 
The  constitutional  condition  is  revealed  by  the  state  of  the 
blood  and  lungs.  A  history  of  childbirth  or  abortion,  followed 
by  the  non-appearance  of  menstruation,  would  indicate  super- 
involution.  Advanced  life  would  point  toward  a  senile 
cause.  One  must  bear  in  mind  the  possibility  of  this  change 
coming  on  early,  at  times  before  the  age  of  thirty-five  years. 


HYPERTROPHY  OF  THE  CERVIX. 

Varieties. ^Hypertrophy  of  the  cervix  may  be  divided  into 
hypertrophy  of  the  vaginal  portion,  and  hypertrophy  of  the 
supravaginal  portion.  The  latter  is  usually  accompanied  by 
more  or  less  elongation. 

Pathology. — The  vaginal  portion  is  much  enlarged  and 
thickened  by  hyperplastic  changes. 

Etiology. — Unknown.  The  condition  is  a  true  hypertrophic 
growth,  very  uncommon,  and  should  not  be  confused  with 
simple  thickening  occurring  as  a  result  of  chronic  inflamma- 
tion following  laceration  at  childbirth. 

Symptoms. — Hypertrophy  of  the  vaginal  portion  is  char- 
acterized by  a  general  increase  in  size,  which  may  be  so  exten- 
sive as  to  cause  its  protrusion  through  the  vaginal  oriflce. 
The  patient  has  in  general  bearing-down  pains  in  the  pelvis, 


HYPEBELONGATION  OF  THE  CERVIX  67 

leucorrhea,  discomfort  in  walking,  and  ulceration  and  excori- 
ation of  the  cervix  when  it  protrudes  at  the  vulva. 

Diagnosis. — The  vagina  is  found  filled  to  a  more  or  less 
extent  by  the  enlargement  of  the  cervix.  The  fornices  are  of 
normal  depth,  and  the  fundus  uteri  is  found  at  its  normal 
height  in  the  pelvis. 

Treatment. — Amputation  of  the  cervix. 


HYPERELONGATION  OF  THE  CERVIX. 

Definition. — A  lengthening  of  the  supravaginal  portion  of 
the  cervix. 

Pathology. — This  condition  is  most  commonly  met  with  in 
prolapse  of  the  uterus,  but  may  exist  unaccompanied  by 
descent  of  the  fundus.  The  cervix  is  drawn  out  and  narrow, 
at  times  hardly  thicker  than  a  whip  cord. 

Etiology. — The  elongation  is  tensile  in  origin,  due  to  down- 
ward traction  on  the  cervix  exerted  by  a  rectocele  or  cystocele 
working  against  the  uterine  supports.  If  the  patient  is  put  to 
bed  and  the  bowels  kept  loose,  thereby  excluding  this  mechani- 
cal factor,  the  elongation  shows  a  marked  tendency  to  subside, 
and  we  often  see  a  greatly  lengthened  cervix  reduced  one-half 
or  more  in  a  few  weeks  with  no  other  treatment.  In  com- 
plete laceration  of  the  perineum,  where  a  rectocele  cannot 
develop,  hyperelongation  of  the  cervix  is  unknown. 

The  symptoms  are  those  of  the  accompanying  cystocele  or 
rectocele.  When  the  cervix  is  so  elongated  as  to  appear  at 
the  vulva  troublesome  friction  ulcers  arise. 

Diagnosis. — The  vaginal  outlet  is  relaxed,  and  there  is  a 
marked  rectocele,  bulging  at  the  introitus  with  every  expul- 
sive effort.  A  cystocele  is  also  commonly  present,  so  that  the 
vaginal  fornices  are  shallow  or  entirely  obliterated.  Bimanual 
examination  may  or  may  not  show  the  fundus  at  its  normal 
level  in  the  pelvis,  and  the  thin  stretched-out  cervix  may  be 
easily  palpated  between  the  index  finger  and  thumb  in  the 


68  THE   UTERUS 

vagina.     Introduction  of  the  uterine  sound  demonstrates  a 
marked  increase  in  the  distance  from  external  os  to  fundus. 

Treatment. — Amputation  of  the  cervix,  and  repair  of  the 
rectocele  and  perineum.  Several  weeks  rest  in  bed  with 
daily  vaginal  douches  should  precede  the  operation. 


LACERATION  OF  THE  CERVIX. 

Definition. — A  solution  of  continuity  in  the  lower  segment 
of  the  uterus. 

Varieties  and  Pathology. — The  most  usual  form  encountered 
is  a  left  unilateral  tear.  Next  in  frequency  come  the  bilateral 
and  stellate  tears.  Anteroposterior  lacerations  are  of  rare 
occurrence.  Lacerations  of  the  cervix  are  found  in  about  30 
per  cent,  of  all  parous  women,  and  a  well-marked  tear  is  one 
of  the  most  reliable  signs  of  previous  parturition.  The  imme- 
diate effect  of  laceration  of  the  cervix  is  hemorrhage,  depend- 
ent in  severity  on  the  extent  of  the  lesion.  The  remote  effect 
is  interference  with  involution;  the  cervix  is  congested  and 
inflamed,  and  its  tissues  become  hypertrophied,  hard,  and 
indurated.  Erosion  of  the  mucous  membrane  and  cystic 
degeneration  of  the  cervical  glands  result. 

Etiology. — The  majority  of  lacerations  of  the  cervix  occur 
during  parturition  as  the  result  of  delivery  through  an  imper- 
fectly dilated  cervix.  In  cases  of  spontaneous  delivery, 
especially  if  precipitate,  we  often  find  well-marked  lacera- 
tions, but  it  is  during  the  performance  of  the  various  obstet- 
rical operations  through  a  partially  dilated  cervix  that  the 
greatest  injuries  are  sustained.  A  small  percentage  of  lacera- 
tions result  from  rapid  miscarriages,  and  some  few  are 
caused  by  careless  instrumental  dilatation. 

The  symptoms  may  be  divided  into  immediate  and  remote. 
The  immediate  signs,  when  the  laceration  is  severe,  are 
hemorrhage  and,  later,  subinvolution.  The  remote  symptoms 
are  many  and  oftentimes  obscure.     Leucorrhea,  thick  and 


CATARRH  OF  THE  CERVIX  69 

mucoid  in  character,  profuse  menstruation  and  sterility  are 
the  common  symptoms.  When  the  tear  has  extended  through 
the  internal  os,  resulting  in  an  ''open-door"  uterine  cavity 
above,  habitual  abortion  is  a  prominent  symptom. 

Diagnosis. — The  examining  finger  in  palpation  outlines  the 
Assuring  of  the  cervix;  the  presence  of  hardened  areas  caused 
by  the  formation  of  cicatricial  tissue,  and  a  patulous  os  often 
admitting  the  finger  tip.  With  the  speculum  the  cleft  in  the 
cervix  is  easily  seen,  and  the  anterior  or  posterior  lip,  or  both, 
will  be  found  covered  with  red  irregular  patches,  which  bleed 
readily  upon  manipulation.  These  are  caused  by  erosion  of 
the  epithelium  from  the  cervical  canal,  which  the  ectropion  of 
the  lips  resultant  on  the  laceration  has  turned  out  into  the 
vagina.  When  a  good  view  of  the  cervix  cannot  be  obtained 
by  the  use  of  the  speculum  alone  it  should  be  grasped  by  a 
traction  forceps  and  drawn  into  the  field  of  vision. 

Treatment. — Proper  tampon  treatment  will  do  much  toward 
improving  the  condition  in  mild  cases.  Tampons  of  ichthyol, 
10  per  cent.,  in  glycerin  introduced  twice  a  week  against  the 
cervix  and  allowed  to  remain  in  place  forty-eight  hours  will 
often  relieve  many  of  the  symptoms. 

After  childbirth,  immediate  suture  of  the  laceration  should 
be  practised  when  possible.  Secondary  repair  is  indicated 
when  the  tear  extends  through  the  internal  os,  and  in  cases 
of  extensive  erosion. 

CATARRH  OF  THE  CERVIX. 

Varieties. — Cervical  catarrh  may  be  either  acute  or  chronic. 
The  acute  variety  is  seen  most  often  as  part  of  a  general  in- 
fection involving  both  body  and  cervix,  and  will  be  described 
later  under  acute  endometritis.  The  chronic  variety  is  a  most 
common  condition,  and  difficult  to  treat  successfully. 

Definition. — Catarrh  is  an  inflammatory  condition  involving 
the  mucous  membrane  of  the  cervical  canal,  otherwise  known 
as  endocervicitis. 


70  THE   UTERUS 

Pathology. — The  surface  of  the  mucous  membrane  is 
covered  with  a  single  layer  of  epithelial  cells  forming  a  new 
glandular  secreting  surface  containing  many  recesses  and 
papillae.  This  addition  to  the  extent  of  the  secreting  surface 
causes  an  increase  in  the  leucorrheal  discharge.  The  whole 
substance  of  the  cervix  is  likewise  affected  by  the  inflamma- 
tory process.  The  origin  of  the  new  epithelial  structure  is  in 
dispute.  Veit  holds  it  is  produced  by  proliferation  of  the  cells 
of  the  deep  layer  of  the  rete  Malpighii;  Hart  and  Barbour, 
that  it  is  occasioned  by  proliferation  of  the  epithelium  lining 
the  cervical  glands.  There  is  an  increase  in  connective  tissue, 
retention  cysts  form  in  the  glands  of  Nabothi,  and  single 
large  cysts  sometimes  develop  in  the  cervix,  due  to  obstruc- 
tion of  the  mucous  glands. 

Etiology. — The  most  important  cause  is  injury  and  lacera- 
tions of  the  cervix.  Gonorrhea  is  a  relatively  frequent  cause. 
Retrodisplacements  of  the  uterus  producing  passive  conges- 
tion in  the  cervix  may  be  a  factor. 

Symptoms. — Leucorrhea,  profuse  and  frequent  menstru- 
ation, pain  in  the  back  and  loins,  and  sterility. 

Diagnosis. — On  introducing  the  speculum  and  examining 
the  cervix  a  string  of  thick  mucus  is  seen  presenting  at  the 
external  os,  and  in  parous  women  usually  signs  of  laceration 
and  erosion  of  the  cervix  are  present.  A  thin  watery  dis- 
charge from  the  cervix  usually  accompanies  endometritis, 
while  a  thick  purulent  discharge  is  indicative  of  gonorrhea. 

Treatment. — A  complete  cure  is  difficult  to  effect.  Hot 
vaginal  douches  containing  sulphate  of  zinc  (5j  to  Oj)  should 
be  given  for  ten  minutes  every  night.  Local  application  of 
tincture  of  iodine  twice  a  week  for  several  months.  Displace- 
ments of  the  uterus  should  be  corrected,  and  lacerations  of 
the  cervix  repaired.  When  subinvolution  of  the  uterus  exists, 
ichthyol  (10  per  cent.)  and  glycerin  tampons  should  be  inserted 
into  the  vagina  behind  the  cervix  twice  a  week.  In  nulliparae 
congenital  erosions  of  the  cervix  call  for  operative  repair. 
Local  depletion  of  the  cervix  by  scarification  is  of  value, 


ENDOMETRITIS  71 

ENDOMETRITIS. 

Definition. — Endometritis  is  an  inflammation  of  the  uterine 
mucosa,  more  or  less  transitory  in  character,  with  a  tendency 
to  extend  to  the  Fallopian  tubes  and  peritoneum.  Its  varieties 
are  acute  or  chronic. 

Acute  Endometritis. — Pathology. — The  whole  mucosa  is 
inflamed;  the  glandular  elements  are  increased;  there  is  an 
infiltration  of  the  connective  tissue  with  leukocytes;  cell 
proliferation  occurs,  and  subsequent  degeneration  of  the 
epithelium  with  early  destruction  of  its  ciliated  cells.  In 
severe  cases  the  whole  endometrium  is  destroyed  and  the 
deeper  muscular  tissues  of  the  uterus  invaded;  the  veins  and 
lymphatics  are  involved  and  the  disease  spreads  to  the  sur- 
rounding peritoneum  and  cellular  tissues,  and  may  even 
reach  the  pelvic  veins  and  lymphatics. 

Etiology. — Endometritis  may  occur  during  the  course  of 
any  acute  exanthem,  and  occasionally  upon  exposure  to  cold 
during  the  monthly  period  of  pelvic  congestion.  The  most 
frequent  exciting  causes  are  microorganisms :  the  gonococcus, 
streptococcus,  staphylococcus,  and  sapremic  bacteria  being 
the  most  important. 

Gonorrheal  Endometritis. — Symptoms. — General  pelvic 
pain,  intermittent  at  first  and  then  constant,  with  rapid  eleva- 
tion of  temperature  and  pulse.  A  purulent  discharge  from 
the  cervix  appears  early,  usually  on  the  second  day,  and 
dysuria  and  ardor  urinse  are  early  symptoms.  In  15  per  cent, 
of  the  cases  there  is  an  accompanying  vaginitis,  while  salpin- 
gitis, pyosalpinx,  and  local  peritonitis  are  common  secjuelse. 

Diagnosis. — Absolute  when  gonococci  are  found  in  the 
discharge.  On  examination  the  uterus  is  found  extremely 
sensitive  to  pressure,  and  the  vagina  and  urethra  reddened, 
edematous,  and  bathed  in  pus. 

Treatment. — The  cervix  is  dilated  and  the  interior  of  the 
uterus,  cervical  canal,  and  vagina  swabbed  out  with  a  10  per 
cent,  silver  nitrate  solution.   Subsequent  daily  vaginal  douches 


72  THE   UTERUS 

of  bichloride  solution  (1  to  5000)  followed  by  normal  saline 
solution  should  be  given  for  at  least  one  week.  The  bowels 
should  be  kept  well  open,  and  opiates  may  be  necessary  to 
relieve  the  pain. 

Septic  Puerperal  Endometritis. — Puerperal  sepsis  may 
occur  during  the  first  few  weeks  after  delivery,  usually  within 
the  first  few  days,  and  is  an  infection  due  to  the  streptococcus 
or  the  staphylococcus. 

Symptoms. — The  attack  is  usually  ushered  in  by  a  chill, 
preceded  by  a  steady  rise  of  temperature  and  pulse.  The  face 
is  flushed  at  first,  but  becomes  pale  and  the  expression  anxious 
as  the  disease  advances.  Pain  is  slight  or  absent.  The  lochia 
becomes  diminished  or  ceases  entirely,  and  is  without  odor. 
The  mortality  is  from  5  to  25  per  cent. 

Diagnosis. — It  is  of  the  utmost  importance  that  .an  early 
diagnosis  be  made  and  the  disease  distinguished  from  putrid 
endometritis.  For  this  purpose  the  secretion  should  be  taken 
directly  from  the  uterine  cavity  and  examined  for  streptococci 
and  staphylococci.  The  interior  of  the  uterus,  under  careful 
exploration  by  the  finger,  will  prove  to  be  smooth  and  contain 
no  debris.  In  putrid  endometritis  the  surface  is  rough, 
retained  placenta  or  blood  clots  will  be  found,  and  the  dis- 
charge will  have  an  offensive  odor. 

Treatment. — Never  use  the  curette.  Having  explored  the 
uterus  and  found  it  empty,  irrigate  with  normal  salt  solution 
and  pack  with  10  per  cent,  iodoform  gauze.  Frequent  saline 
enemata,  liquid  diet,  stimulation  with  brandy  and  strychnine 
in  full  doses,  and  free  catharsis  should  be  employed.  Intra- 
venous infusion  of  normal  saline  solution  is  indicated  in 
desperate  cases,  also  a  posterior  cul-de-sac  incision  and 
thorough  packing  of  the  pelvic  cavity  with  10  per  cent,  iodo- 
form gauze  (Pryor).  The  gauze  in  both  the  uterus  and  pelvis 
should  be  gradually  withdrawn,  beginning  on  the  third  and 
ending  on  the  ninth  day. 

Putrid  Endometritis. — Etiology  and  Pathology. — Putrid 
endometritis  is  caused  by  the  presence  of  dead  material,  such 


ENDOMETRITIS 


73 


as  retained  secundines,  sloughing  polypi,  or  fibroids  infected 
by  the  saprophytic  bacteria  from  the  vagina. 

Symptoms. — An  initial  chill  is  occasionally  present.  There 
are  high  fever,  tense,  bounding  pulse,  flushed  face,  and  little 
or  no  pain.  A  foul,  putrid  discharge  is  present  except  when 
a  large  blood  clot  blocks  the  cervical  canal.  In  postpartum 
cases  the  lochia  is  scant  but  rarely  suppressed.  Upon  exami- 
nation there  is  little  or  no  tenderness  in  the  uterus  or  appen- 
dages. 

The  diagnosis  is,  as  a  rule,  easy,  from  the  history  and  clinical 
symptoms;  but  great  care  should  be  taken  to  distinguish 
putrid  endometritis  from  puerperal  septicemia. 


Differential  Diagnosis. 


Forms  of  endometritis  compared. 

Symptoms  compared. 

Septic  puerperal  endome- 

Putrid endometritis. 

tritis. 

Onset 

Sudden  with  chill 

Gradual,  with  or  without 
chill 

Temperature     .... 

High  and  continuous 

Maximima  early,  with  sub- 
sequent fluctuations 

Pulse 

Rapid,   thin,   and   later 

Full     and     regular,     rarely 

thready,  130  and  over 

over  120 

Discharge 

Scant  and  odorless,   thin  at 
first,  and  purulent  later 

Free  and  putrid 

Microscope       .... 

Streptocci   or    staphylococci 
pyogenes 

Saprophytic  bacteria 

Interior  of  uterus 

Smooth,  no  debris  present 

Ragged,  debris  present 

Treatment. — The  cervix  should  be  dilated  and  the  cavity  of 
the  uterus  thoroughly  explored  with  the  finger.  All  debris 
should  be  removed,  rough  surfaces  curetted,  a  copious  saline 
irrigation  given,  and  the  uterus  firmly  packed  with  10  per  cent, 
iodoform  gauze,  which  should  not  be  removed  too  early, 
about  the  third  to  ninth  dav.     Stimulation  when  indicated. 


74  THE  UTERUS 

Free  catharsis  and  a  liquid  diet  until  the  temperature  becomes 
normal. 

Chronic  Endometritis. — Definition. — A  chronic  inflamma- 
tion of  the  uterine  mucosa  characterized  by  marked  hyper- 
trophy of  the  mucous  membrane. 

Pathology. — The  endometrium  is  much  thickened  and  vas- 
cular. The  glandular  elements  are  increased,  and  the  inter- 
cellular substance  is  thickened  by  exudation.  Several  different 
varieties  are  recognized:  a  glandular,  interstitial,  mixed,  and 
the  fungoid  variety  of  Olshausen.  Ultimately  the  mucosa 
becomes  atrophied,  the  ciliated  and  cylindrical  epithelium  are 
lost,  and  finally,  the  mucous  membrane  disappears  entirely, 
to  be  replaced  by  a  layer  of  connective  tissue. 

Etiology. — Chronic  endometritis  is  occasionally  the  result 
of  the  acute  form,  but  most  frequently  arises  independently. 
Subinvolution  of  the  uterus  following  parturition,  and  dis- 
placements of  the  uterus,  are  the  most  frequent  causative 
factors.  Foreign  bodies  in  the  uterus  and  direct  injuries,  or 
infections,  may  give  rise  to  chronic  endometritis.  A  senile 
form  exists  coming  on  after  the  menopause. 

Symptoms. — Menorrhagia,  dysmenorrhea,  leucorrhea,  pain 
in  the  back,  pelvis,  and  loins,  with  sterility,  or  habitual 
abortion. 

Diagnosis. — Generally  to  be  made  from  the  clinical  symp- 
toms, of  which  increased  duration  of  the  menstrual  flow,  with 
a  prolongation  over  the  intermenstrual  period,  is  the  most 
constant.  To  differentiate  endometritis  and  malignant  disease 
in  its  early  stages  is  of  paramount  importance,  and  for  this 
purpose  the  curette  is  invaluable.  The  scrapings  removed 
and  examined  under  the  microscope  will  often  show  the 
lesion  present,  and  determine  the  diagnosis. 

Local  Treatment. — A  thorough  vaginal,  and  in  virgins 
rectal,  examination  should  be  made,  and  any  displacement  of 
the  uterus  corrected  and  foreign  bodies,  such  as  polypi  and 
fibroids,  removed.  Subinvolution  calls  for  prolonged  hot 
douches  daily  and  tampons  of  boroglyceride,  or,  where  there 


METRITIS  75 

is  much  pain,  ichthyol,  10  per  cent,  in  glycerin.  These  should 
be  inserted  high  into  the  vagina,  behind  the  cervix,  three 
times  a  week,  and  allowed  to  remain  twenty-four  hours. 
Where  hemorrhage  is  a  prominent  symptom,  curettage  affords 
the  best  hope  of  effecting  a  cure;  but  where  the  discharge 
is  mucopurulent  in  character,  intra-uterine  medication  is 
necessary.  This  may  be  given  independently  of,  or  follow  the 
curettage.  The  interior  of  the  uterus  and  cervical  canal  are 
thoroughly  and  carefully  swabbed  with  caustic  solution,  such 
as  pure  carbolic  acid,  or,  better,  Churchill's  tincture  of  iodine. 
Subsequent  applications  may  be  required.  The  preliminary 
use  of  the  curette  is  desirable.  Cauterization  of  the  mucosa 
by  steam  is  useful  in  severe  hemorrhagic  cases. 

Constitutional  treatment  must  be  carried  out  as  well,  and 
proper  attention  should  be  given  to  the  bowels  and  daily 
hygiene. 

METRITIS. 

Definition  and  Varieties. — Metritis  is  an  inflammation  of  the 
muscular  walls  of  the  uterus,  and  is  either  acute  or  chronic. 

Acute  Metritis. — Pathology. — There  is  marked  enlarge- 
ment of  the  uterus,  its  walls  are  thickened  and  soft,  with  en- 
larged veins,  and  an  infiltration  of  the  muscular  tissue  with 
pus  corpuscles.  The  endometrium  is  thickened  and  vascular, 
while  the  outer  peritoneal  surface  is  covered  with  plastic 
exudate. 

Etiology. — Metritis  is  caused  by  extension  of  the  inflamma- 
tion in  acute  endometritis.  It  is  most  commonly  seen  in  puer- 
peral sepsis  and  acute  gonorrhea. 

Symptoms. — Fever  and  elevation  of  the  pulse  in  direct 
proportion  to  the  severity  of  the  infection  are  present.  Men- 
struation is  usually  diminished  and  may  be  suppressed. 
Pelvic  pain  is  constant  and  aggravated  by  motion  and  on 
emptying  the  bladder  and  rectum.  Many  of  the  symptom* 
are  those  of  the  primary  disease  (see  Acute  Endometritis). 


76  .      THE   UTERUS 

Diagnosis. — Metritis  is  usually  accompanied  by  acute 
endometritis  and  pelvic  peritonitis.  It  rarely  exists  alone. 
Abscess  formation  is  the  most  serious  complication  and  its 
possibility  should  always  be  borne  in  mind.  Vaginal  exami- 
nation shows  a  large  tender  uterus,  with  more  or  less  restric- 
tion of  mobility. 

Treatment. — Much  that  has  been  said  under  the  treatment 
of  acute  endometritis  applies  here.  The  cause  should  be 
sought  and  removed.  Curettage  and  irrigation  of  the  uterine 
cavity,  where  it  contains  infecting  material,  is  indicated. 
Where  the  metritis  is  a  complication  of  pelvic  peritonitis  the 
treatment  must  be  largely  medical.  Absolute  rest  in  bed, 
hot  turpentine  stupes  over  the  lower  part  of  the  abdomen, 
enemata — not  purgatives — for  the  bowels,  and  opium  sup- 
positories when  indicated.  Prolonged  hot  (115°)  vaginal 
douches  of  twenty  minutes'  duration  are  of  great  service,  and 
should  always  be  given  when  well  borne  by  the  patient. 

Chronic  Metritis. — Pathology. — There  is  an  increase  of 
connective  tissue  developed  in  the  walls  of  the  uterus,  the 
muscular  tissue  remaining  little  if  any  changed.  In  the  first 
stage  the  uterus  is  enlarged,  soft,  and  hyperemic;  in  the 
later  stage  it  becomes  hard,  indurated,  and  anemic.  With  the 
increase  in  thickness  of  the  uterine  walls  there  is  an  accom- 
panying increase  in  the  size  of  the  uterine  cavity. 

Etiology. — Most  of  the  cases  of  chronic  metritis  develop  as 
the  result  of  some  interference  with  the  normal  postpartum 
involution  of  the  uterus.  The  most  potent  factors  are: 
retained  placental  tissues,  blood  clots,  lacerations  of  the  cervix 
non-lactation,  too  early  rising  after  delivery,  and  frequent 
miscarriages.  Prolonged  venous  stasis,  the  result  of  dis- 
placements, is  an  active  etiological  factor. 

The  symptoms  usually  date  from  a  previous  confinement  or 
abortion.  Weakness  and  pain  in  the  back,  irregular  and 
increased  menstruation,  and  leucorrhea.  Repeated  abortions 
may  occur  in  the  early  stages,  and  sterility  is  the  rule  when 
the  disease  is  well  established. 


SUPERINVOLUTION  OF  THE   UTERUS  'J'J 

Diagnosis. — On  examination  the  uterus  is  found  slightly 
enlarged,  its  cavity  increased  in  depth,  and  the  whole  organ 
often  fixed  by  adhesions  in  a  retroverted  or  retroflexed  posi- 
tion. To  differentiate  metritis  from  general  fibrosis  of  the 
uterus,  or  small  fibroid  tumors,  is  often  impossible,  except  by 
operation.  Great  care  is  at  times  necessary,  however,  to 
distinguish  metritis  from  early  pregnancy,  the  possibility  of 
which  should  always  be  borne  in  mind  and  the  sound  never 
used  except  directly  after  menstruation.  In  pregnancy  the 
uterus  is  soft,  elastic,  and  shows  progressive  enlargement; 
menstruation  is  absent.  In  chronic  metritis  the  uterus  may 
be  soft  or  hard,  but  is  usually  firm  and  non-elastic,  constant 
in  size,  with  the  exception  of  a  slight  increase  preceding 
menstruation,  and  which  subsides  as  the  pelvic  congestion 
wanes. 

Treatment. — Displacements  must  always  be  corrected  w^hen 
possible,  and  pelvic  circulation  stimulated  by  prolonged  hot 
vaginal  douches,  a  daily  laxative  for  the  bowels,  and  tampons 
of  boroglyceride  every  other  day.  For  the  menorrhagia, 
fluidextract  of  ergot,  Tr^xx,  every  three  hours,  is  indicated.  In 
many  cases  styptol  (neutral  cotarnine  phthalate),  in  J-grain 
doses  given  every  three  hours,  is  of  value.  Tincture  of  iodine 
to  the  cervix  and  vaginal  vault  during  the  intermenstrual 
period  is  of  service.  Lacerations  of  the  cervix  may  call  for 
repair. 

SUPERINVOLUTION  OF  THE  UTERUS. 

Definition. — An  acquired  atrophic  condition  of  the  uterus 
following  childbirth  or  miscarriage. 

Pathology. — The  uterus  is  much  smaller  than  normal. 
Its  walls  are  thin  and  of  dense  fibrous  consistency  and  its 
mucous  membrane  scanty,  or  absent  entirely.  There  is 
usually  an  accompanying  atrophy  of  the  ovaries.  The  cervix 
is  small,  hard,  and  nearly  or  quite  flush  with  the  vaginal 
vault.    The  os  is  contracted. 


78  MALIGNANT  DISEASE  OF   THE  UTERUS 

Etiology. — The  frequency  of  this  condition  has  been  esti- 
mated at  from  1  to  2  per  cent.  Prolonged  lactation,  anemia, 
tuberculosis,  and  puerperal  sepsis  are  supposed  causes.  It 
may  be  produced  by  too  frequent  and  too  energetic  curettage. 

Symptoms. — Sterility,  amenorrhea,  and  neurasthenia. 

Diagnosis. — A  small,  flat,  pale  cervix  is  at  once  suggestive. 
The  fundus  is  proportionately  small  and  only  located  with 
difficulty.  It  may  be  necessary  to  pass  a  sound  in  order  to 
demonstrate  its  presence. 

Treatment. — Unsatisfactory.  Iron  and  constitutional  treat- 
ment should  be  employed. 

The  prognosis  is  most  favorable  in  those  cases  due  to  pro- 
tracted lactation.  Atrophy  resulting  from  puerperal  sepsis 
is  incurable. 


CHAPTER   VII. 
MALIGNANT  DISEASE  OF  THE  UTERUS. 

There  are  two  principal  types  of  malignant  disease  of  the 
uterus,  viz.,  epithelial  and  connective  tissue:  carcinoma  is  an 
example  of  the  former,  and  sarcoma  of  the  latter.  Two  rare 
forms  exist — adenoma  malignum  and  deciduoma  malignum. 

As  we  find  the  cervix  differing  anatomically  from  the  body 
of  the  uterus,  so  we  expect  to  find  distinct  pathological  dif- 
ferences as  well.  While  fibroid  tumors  are  common  in  the 
body  of  the  uterus,  they  are  rare  in  the  cervix.  In  carcinoma 
the  cervix  is  the  seat  of  the  disease  in  95  per  cent,  of  all  cases, 
while  the  fundus  is  rarely  involved. 

CARCINOMA  OF  THE  CERVIX. 

Definition. — Carcinoma  is  a  malignant  disease  of  the  neck 
of  the  uterus. 

Pathology. — There  are  two  types  of  carcinoma  of  the  cervix, 
according  to  whether  the  disease  develops  on  the  external, 


CARCINOMA  OF  THE  CERVIX  79 

or  internal  aspect  of  the  cervix.  The  external  form  originates 
in  the  deeper  layer  of  squamous  cells  covering  the  vaginal 
aspect,  and  the  resulting  proliferation  of  the  epithelium 
forms  a  mushroom-like  tumor  projecting  into  the  vagina — 
the  so-called  epithelioma.  The  internal  or  glandular  cancer 
originates  from  the  cervical  glands  or  epithelium  lining,  the 
cervical  canal,  and  the  proliferating  epithelium  extends  into 
iYie  gland,  or  the  connective  tissue,  as  the  case  may  be.  Thus, 
a  tubular  structure  is  found  having  a  lumen  covered  by  several 
layers  of  epithelial  cells.  The  type  of  cell  arrangement  follows 
in  general  that  of  a  gland,  only  the  arrangement  is  in  layers 
without  definite  order. 

The  disease  may  begin  in  one  of  three  clinical  forms:  (1) 
As  hard  nodules  lying  under  the  mucous  membrane.  These 
increase  in  size,  work  their  way  to  the  surface,  and  ulcerate. 
(2)  Beginning  inside  the  cervical  canal,  the  disease  works 
along  the  mucous  membrane  excavating  the  canal.  (3)  As 
an  ulcerating  surface  on  the  vaginal  aspect  of  the  cervix,  or  as 
an  irregular  tumor  of  papillary  growth  projecting  into  the 
vagina.  Only  in  the  early  stages  can  these  three  clinical 
forms  be  differentiated;  later  they  become  indistinguishable. 
The  growth  spreads  either  downward  into  the  vagina,  up  into 
the  uterus,  or  laterally  into  the  connective  tissue  of  the  pelvis. 
The  first  two  are  the  more  favorable  for  operative  treatment; 
the  latter  offers  the  greatest  difficulties.  Dissemination  of  the 
growth  takes  place  through  the  lymphatics  into  the  lumbar, 
iliopelvic,  and  inguinal  glands.  The  latter  are  rarely  affected, 
but  the  iliopelvic  are  frequently  involved,  and  may  be 
readily  palpated  "per  rectum  when  much  enlarged.  In 
the  late  stages  involvement  of  the  neighboring  organs  is 
common,  so  that  vesicovaginal  and  rectovaginal  fistulse 
often  result. 

Etiology. — The  immediate  etiology  is  as  yet  unknown. 
TTeredity,  age,  and  lowered  vital  powers  are  general  pre- 
disposing causes,  while  erosions  and  lacerations  of  the  cervix 
are  supposed  to  act  as  local  exciting  causes. 


80 


MALIGNANT  DISEASE  OF  THE   UTERUS 


Symptoms. — Hemorrhage  is  the  early  and  all-important 
symptom.  Its  significance  should  never  be  underestimated. 
After  the  menopause  it  is  almost  always  pathognomonic  of 
cancer.  Later,  an  offensive  serosanguinous  discharge  devel- 
ops, with  loss  of  weight  and  general  debility. 

Pain  is  not  an  early  symptom,  appearing  only  after  the 
disease  has  spread  to  the  surrounding  tissues. 

Diagnosis. — Vaginal  examination  shows  an  enlarged  thick- 
ened cervix  and  on  one  or  both  lips  an  ulcerated  surface  or  a 

Fig.  21 


Carcinoma  of  the  cervix. 


distinct  tumor,  bleeding  readily  upon  manipulation.  A  sec- 
tion of  this  tissue  examined  under  the  microscope  will  gener- 
ally determine  the  diagnosis. 

In  advanced  cases  induration  in  the  broad  ligaments  and 
restriction  of  the  normal  mobility  of  the  uterus,  with  enlarge- 
ment of  the  iliopelvic  glands,  may  be  made  out. 

Treatment. — In  recent  cases  early  operation,  as  soon  as  the 
diagnosis  is  made,  offers  the  only  hope  of  cure.  The  operation 
should  be  of  radical  character,  and  calls  for  the  removal  of  the 
uterus,  appendages,  and  as  much  of  the  broad  ligaments  and 


CARCINOMA  OF  THE  FUNDUS  OF  THE   UTERUS     81 

upper  third  of  the  vagina  as  possible.    It  is  advisable  often 
to  remove  the  iliopelvic  and  lumbar  glands  as  well. 

In  old  cases  advanced  beyond  the  stage  of  radical  operation, 
where  there  is  profuse  hemorrhage,  ligation  of  the  internal 
iliac,  round  ligament,  and  obdurator  arteries  will  control  this 
distressing  feature,  and  by  shrinking  the  growth  relieve  much 
of  the  pelvic  pain.  Ergot  and  adrenalin  internally,  with  an 
intra-uterine  tampon  of  adrenalin  gauze,  are  valuable  pal- 
liative measures  in  hemorrhagic  cases.  When  the  discharge 
is  very  offensive,  daily  vaginal  douches  should  be  given — 
bichloride  (1  to  2000)  or  Condy's  fluid. 

I^ — Potassium  permanganate 53  parts. 

Alum  sulphate  crystals 333     " 

Hot  water 777     " 

The  pain  may  only  be  controlled  by  the  free  administration 
of  opium,  which  should  be  deferred  as  long  as  possible. 


CARCINOMA  OF  THE  FUNDUS  OF  THE  UTERUS. 

Definition. — A  malignant  disease  of  the  body  of  the  uterus. 

Pathology. — A  rare  disease,  found  in  only  about  2  per  cent, 
of  all  cases  of  uterine  cancer;  starting  either  in  the  epithelium 
of  the  mucosa  or  the  glands.  It  develops  as  a  diffuse  or 
nodular  growth. 

Etiology. — ^Unknown.  Is  more  frequent  in  non-parous 
women  than  in  those  who  have  borne  children. 

Symptoms. — Pain,  hemorrhage,  and  fetid  discharge.  The 
first  two  are  usually  present  early  in  the  disease. 

Diagnosis  .^The  uterus  is  enlarged  and  more  often  found 
freely  movable  than  in  carcinoma  of  the  cervix.  Vaginal 
examination  shows  a  normal  cervix,  with  a  slight  dilatation 
of  the  canal.  C'ertainty  of  diagnosis  should  be  established,  if 
possible,  and  the  (condition  differentiated  from  deciduoma 
malignum,  sloughing  fibroid,  or  retained  placental  tissue. 
6 


82  MALIGNANT  DISEASE  OF  THE   UTERUS 

For  this  purpose  the  cervix  must  be  dilated,  the  uterine  cavity 
explored  with  the  finger,  and  curettings  removed  for  micro- 
scopic examination. 

Treatment. — Complete  early  extirpation  of  the  uterus. 
When  this  is  done  the  chances  of  obtaining  a  cure  are  better 
than  in  carcinoma  of  the  cervix. 


SARCOMA  OF  THE  UTERUS. 

Definition. — A  malignant,  connective-tissue  tumor  of  em- 
bryonic type. 

Pathology. — Sarcoma,  differing  from  carcinoma,  rarely 
develops  in  the  cervix.  Two  forms  are  recognized,  viz.,  a 
diffuse  and  circumscribed.  The  diffuse  form  is  a  growth  of 
the  mucosa  arising  in  the  subepithelial  connective  tissue,  and 
characterized  by  an  infiltration  of  round  cells,  rarely  of  spindle 
cells.  The  mucous  membrane  is  swollen,  becomes  soft  and 
friable,  and  often  breaks  down.  The  circumscribed  form 
originates  in  the  muscular  walls  of  the  uterus,  and  may  be 
submucous,  interstitial,  or  subperitoneal.  The  tumor  much 
resembles  a  fibroid  in  feel  and  appearance.  Secondary 
nodules  occur  in  the  vagina  and  peritoneum. 

Etiology. — Little  is  known  as  to  the  etiology.  Most  fre- 
quent between  the  ages  of  forty  and  fifty.  Sterility  seems  to 
be  a  factor. 

Symptoms. — Hemorrhage  is  an  early  symptom,  with  a  thin, 
watery  discharge  having  little  or  no  odor.    Pain  is  infrequent. 

Diagnosis. — When  the  tumor  presents  at  the  external  os 
as  a  soft,  friable  mass,  diagnosis  is  easy.  If  Hmited  to  the 
uterine  cavity  the  cervix  must  be  dilated,  the  uterus  explored, 
and  curettings  taken  for  microscopic  examination. 

The  uterus  is  enlarged,  forming  a  distinct  tumor,  and  though 
movable  at  first,  early  becomes  fixed.  Differential  diagnosis 
from  carcinoma,  deciduoma  malignum,  and  intra-uterine 
fibroid  is  often  difiicult. 


DECIDUOMA  M ALIGN UM  83 

Treatment. — As  in  carcinoma,  the  treatment  must  be  radi- 
cal, and  complete  removal  of  the  uterus  and  appendages 
practised.    Curetting  is  of  avail  only  as  an  aid  to  diagnosis. 


DECIDUOMA  MALIGNUM. 

Definition. — A  malignant  disease  of  the  uterus  developing 
in  the  puerperium. 

Pathology. — The  uterus  is  enlarged,  its  cavity  gangrenous 
when  the  tumor  breaks  down,  and  secondary  growths  occur 
in  the  cervix  and  lungs.  The  tumor  consists  of  islands  of 
multinucleated  large  cells,  surrounded  by  loose  tissue  con- 
taining individual  cells,  and  penetrates  the  muscular  wall  of 
the  uterus.  Metastases  in  distant  organs  are  a  common 
feature. 

Etiology. — Develops  shortly  after  delivery,  abortion,  or 
hydatid  mole.  The  clinical  resemblance  to  sarcoma  suggests 
that  it  may  be  an  ordinary  sarcoma  modified  by  pregnancy, 
or  developed  from  the  products  of  conception. 

Symptoms. — Hemorrhage  is  usually  the  first  symptom,  and 
is  followed  later  by  a  foul  discharge  and  fever.  The  course 
of  the  disease  is  rapid,  and  secondary  growths  in  the  vagina 
and  labia  may  be  the  first  symptoms  to  attract  attention. 

Diagnosis. — Absolute,  from  the  examination  of  tissue 
removed  by  the  curette.  The  uterus  is  found  enlarged  and 
oftentimes  increases  rapidly  in  size.  Metastases  in  the  lungs, 
vagina,  liver,  and  spleen  are  frequent.  The  disease  is  one  of 
short  duration,  death  occurring  in  from  two  to  six  months. 

Treatment. — Success  can  only  be  obtained  by  complete 
removal  of  the  uterus  and  appendages  before  metastases  have 
developed.    The  mortality  is  over  50  per  cent. 


CHAPTER   VIII. 

BENIGN  TUMORS  OF  THE  UTERUS. 

FIBROMYOMATA. 

Definition. — Non-malignant  newgrowths  of  the  uterus. 

Frequency. — Of  all  the  newgrowth  formations  of  the  uterus, 
the  fibromyomata  are  most  often  encountered.  Various 
observers  estimate  their  frequency  at  from  20  to  40  per  cent, 
in  all  women  over  thirty-five  years  of  age.  Contrasted  with 
cancer,  they  show  marked  differences,  not  without  interest. 
Appearing  early  in  life,  they  attack  the  well-to-do;  are  more 
common  in  sterile  women,  and  rarely  endanger  life  except  by 
complications. 

Pathology. — Occur  more  often  in  the  body  than  in  the  cer- 
vix of  the  uterus.  When  located  in  the  body,  the  posterior 
wall  is  the  common  site.  They  are  composed  of  non-striped 
muscular  fiber  and  fibrous  tissue,  are  of  firm  consistency,  and 
a  cut  section  presents  a  pale,  glistening,  uneven  surface.  A 
capsule  of  loose  fibrous  tissue  generally  surrounds  the  growth. 
Few  bloodvessels  penetrate  the  tumor,  nutrition  being  derived 
from  the  surrounding  tissues,  which  are  extremely  vascular. 

Slow  growth,  in  direct  proportion  to  the  predominance  of 
the  fibrous  over  the  muscular  tissue,  is  the  rule,  but  during 
pregnancy  a  rapid  increase  in  size  is  often  observed.  In  the 
puerperium  they  become  smaller  as  the  uterus  involutes. 
An  arrest  in  development,  and  often  marked  decrease  in  size, 
may  take  place  after  the  menopause,  but  this  is  variable  and 
may  not  be  counted  on. 

Varieties. — All  fibromyomata  begin  as  interstitial  or  intra- 
mural growths,  but  with  increase  in  size  project  either  into 
the  walls  of  the  uterus,  or  toward  the  mucous  or  peritoneal 
surface.  Three  varieties  are,  therefore,  recognized — inter- 
stitial, submucous,  and  subperitoneal. 
(  84  ) 


FIBROMYOMATA 


85 


Interstitial  fibromata  remain  in  the  substance  of  the  uterine 
wall,  are  usually  multiple,  varying  in  size. 


Fig.  22 


Diagram  of  growth  of  uterine  fibroids:  1,  la,  free  submucous;  2,  2a,  encapsulated 
submucous;  3,  encapsulated  subserous;  4,  free  subserous.     (AUbutt.) 

Fig.  23 


General  uterine  fibrosis,  showing  great  thickening  of  the  uterine  walls. 


86 


BENIGN  TUMORS  OF  THE   UTERUS 


Submucous  fibromata  project  into  the  cavity  of  the  uterus, 
being  covered  by  the  mucosa,  are  attached  to  the  uterus  by  a 
broad  base,  or  pedicle  and  sometimes  undergo  spontaneous 
amputation  and  expulsion  from  the  uterus. 


Fig.  24 


Intra-uterine  fibroid,  small  pyosalpinx.     Large  cyst  of  Morgagni  and  general 

uterine  fibrosis. 


Subperitoneal  fibromata  project  outward  into  the  peritoneal 
cavity,  are  covered  by  peritoneum,  and  generally  peduncu- 
lated. 

Marked  changes  in  the  size  and  position  of  the  uterus  occur 
with  these  different  varieties.  In  the*  interstitial  and  sub- 
mucous types  the  muscular  hypertrophy  in  the  walls  of  the 
uterus  is  marked,  while  with  pedunculated  fibroids  the  uterus 
often  remains  normal  in  size,  but  is  frequently  displaced. 


FIBROMYOMATA  87 

The  fibromyomata  during  their  Hfetime  are  often  the  seat 
of  many  changes.  AUhough  steady  growth  in  the  original 
pathological  direction  is  the  rule,  necrosis,  fatty  or  myxo- 
matous degeneration  may  intervene,  producing  a  marked 
softening,  while  calcification  may  change  the  tumor  to  a  hard, 
stone-like  mass — the  wombstone  of  the  ancients.  Suppura- 
tion is  an  occasional  complication.  Whether  malignant 
degeneration  ever  develops  is  still  a  disputed  point.  Twist 
of  the  pedicle  with  resulting  necrosis  of  the  tumor  may 
occur. 

Etiology. — Of  the  causes  of  fibromyomata  we  know  very 
little.  A  generous  vascular  supply  seems  to  be  necessary  to 
their  growth  and  continued  development,  and  they  seldom 
arise  before  puberty,  or  after  the  menopause.  Between  the 
ages  of  thirty  and  forty  is  the  time  of  greatest  activity. 

Symptoms. — These  are  in  direct  proportion  to  the  size  and 
location  of  the  tumor.  Large  subperitoneal  tumors  with 
plenty  of  room  in  which  to  grow  may  not  cause  any  symptoms 
for  a  long  time,  while  small  submucous  tumors,  and  those 
low  down  in  the  cervix,  produce  early  disturbance.  The 
more  usual  symptoms  are  dysmenorrhea,  menorrhagia, 
sterility,  and  abortion.  Pain  is  caused  by  the  size  and  weight 
of  the  tumor,  and  by  pressure  on  the  bladder,  rectum,  and 
nerves.  Hemorrhoids,  varicose  veins  of  the  legs  and  edema 
appear  as  the  result  of  interference  with  the  venous  circulation. 
Elevation  of  temperature  and  pulse  is  seen  where  necrosis  and 
suppuration  develop.  Death  rarely  results  from  the  tumor 
per  se  except  when  complications  arise.  Intestinal  obstruc- 
tion, resulting  from  the  pressure  of  a  fibroid  in  the  pelvis,  is 
a  rather  rare  though  easily  recognized  complication. 

Diagnosis. — Is  easy  or  difficult,  depending  on  the  size  of  the 
tumor.  The  small  fibroids,  unless  submucous  or  subperi- 
toneal, are  difficult  of  recognition.  When  projecting  into  the 
uterine  cavity,  digital  exploration  will  locate  a  tumor  of  hard 
consistency  springing  from  the  wall  of  the  uterus.  The 
subperitoneal  type,  even  when  quite  small,  may  be  readily 


88  BENIGN  TUMORS  OF  THE  UTERUS 

palpated  through  a  thin  abdominal  wall.  The  interstitial 
variety  produces  a  condition  resembling  general  uterine 
enlargement,  and  must  not  be  confused  with  early  pregnancy; 
when,  however,  the  soft  character  of  the  tumor,  with  other 
accompanying  signs  of  pregnancy  should  clear  the  diagnosis. 
The  large  fibromyomata  extending  above  the  pelvic  brim  are 
easy  of  recognition.  Inspection  shows  an  enlargement  of  the 
abdomen  differing  in  contour  from  either  pregnancy  or  ovarian 
cyst;  while  palpation  gives  a  firm,  solid  tumor  springing  from 
the  pelvis  in  the  median  line.  Intermittent  contractions  are 
absent,  except  in  the  very  soft  variety,  and  auscultation  fails 
to  reveal  a  fetal  heart.  On  vaginal  examination  the  cervix  is 
hard  and  high  up,  while  in  pregnancy  it  is  soft,  and  in  ovarian 
cyst  normal  in  consistency  and  usually  low  down.  If  the 
fibroid  is  pedunculated,  bimanual  examination  may  distinguish 
the  uterus  distinct  from  the  tumor.  Where  it  is  impossible  to 
rule  out  pregnancy,  a  waiting  policy  should  always  be  adopted. 
It  is  very  rare  to  have  cessation  of  menstruation  with  fibro- 
myoma,  but  the  possibility  of  pregnancy  in  a  fibroid  uterus 
must  always  be  borne  in  mind.  The  most  common  error  in 
diagnosis  is  to  mistake  a  normal  pregnant  uterus  for  a  soft 
fibromyoma,  and  the  following  summary  may  aid  in  making 
a  differential  diagnosis: 

Fibromyoma.  Pregnancy. 

Consistency  constant,  though  intermit-  Consistency   varies,    and    intermittent 

tent   contractions  may   occur,  giving  contractions  are  always  present, 
slight   variations. 

Cervix  never  soft,  generally  hard.  Cervix  always  soft. 

Fetal  heart  sounds  absent.  Fetal  heart  sounds  present. 

Fetal  movements  absent.  Fetal  movements  present. 

Menstruation  increased  in  quantity  or  Menstruation  absent, 
unaffected. 

When  fetal  death  has  occurred  it  may  be  impossible  to 
make  a  correct  diagnosis,  but  when  doubt  exists,  wait. 

Treatment. — Many  fibromyomata  live  a  symptomless 
existence  calling  for  little  in  the  way  of  treatment,  either 


FIBROMYOMATA  S9 

palliative  or  radical.  Operative  removal  should,  as  a  rule, 
be  resorted  to,  however,  when  the  symptoms  are  pressing,  for 
palliative  measures  have  little  or  no  effect  in  checking  the 
growth  of  the  tumor.  The  menorrhagia  may  be  controlled 
for  awhile  by  the  administration  of  ergot  in  increasing  doses, 
and  suprarenal  extract  often  proves  of  value.  The  indica- 
tions for  operative  removal  may  appear  early  in  cases  of 
submucous  fibroids,  whereas  the  subperitoneal  form  often 
reaches  enormous  size  before  the  patient  applies  for  treatment. 
Curetting  may  improve  the  menorrhagia  for  a  time  by  remov- 
ing the  diseased  endometrium  usually  present,  but  is  of  only 
temporary  benefit.  Removal  of  the  ovaries,  producing  an 
artificial  menopause,  with  the  idea  of  checking  the  bleeding 
and  stopping  the  growth  of  the  tumor,  has  been  practised  with 
favorable  results  in  small  fibroids,  but  removal  of  the  tumor 
itself  would  probably  have  been  the  simpler  operation. 
Ligation  of  the  uterine  arteries  is  of  service  in  cases  of  severe 
bleeding,  where  removal  of  the  tumor,  on  account  of  the  age 
or  condition  of  the  patient,  is  impracticable,  but  should  not  be 
performed  when  there  is  reason  to  suppose  that  the  tumor  is 
undergoing  necrosis. 

Indications  for  Operation. — Actual  size  of  the  tumor,  pressure 
symptoms,  necrosis,  suppuration,  and  persistent  hemorrhage. 
Location  has  much  to  do  with  determining  operation,  as  in 
intra-uterlne,  pedunculated  growths,  and  those  low  down  in 
the  cervix  obstructing  the  pelvic  oudet. 

Removal  may  be  carried  out  by  either  the  abdominal  or 
vaginal  route.  The  submucous  pedunculated  fibroids  are 
easily  removed,  after  dilating  the  cervix,  by  ligating  or  twisting 
the  pedicle.  On  opening  the  peritoneal  cavity  the  condition 
present  should  be  carefully  studied  and  every  effort  made  to 
preserve  the  uterus  where  possible.  Myomectomy  should  be 
the  rule  and  the  uterus  never  sacrificed,  except  when  advanced 
general  fibrosis  of  its  walls  exist. 


90  BENIGN  TUMORS  OF  THE   UTERUS 


ADENOMYOMA. 

Definition. — A  tumor  composed  of  glandular  and  muscular 
tissues. 

Pathology. — Adenomyomata  are  probably  the  result  of 
infiltration  of  a  fibromyoma  by  glands  from  the  endometrium, 
and  are  of  uncommon  occurrence.  The  glands  are  normal 
uterine  glands  confined  entirely  to  the  newgrowth  and  showing 
no  tendency  to  invade  the  normal  muscular  tissue.  The 
adenomyomata  are,  as  a  rule,  intramural  growths,  have  no 
capsule,  and  are  situated  most  often  at  the  tubal  angles,  and 
in  the  posterior  wall  of  the  uterus.  Three  varieties  are 
recognized — diffuse,  subperitoneal,  and  interligamentary. 

Etiology. — Unknown. 

Symptoms. — Depend  on  the  size  and  situation  of  the 
tumor.  When  diffuse,  it  is  common  to  find  a  history  of  length- 
ened menstrual  periods,  accompanied  by  dull,  grinding  pain 
in  the  back  and  pelvis,  often  extending  down  the  legs.  As  the 
condition  advances  severe  hemorrhages  occur,  becoming  more 
and  more  frequent,  and  at  times  continuous  bleeding  is  pres- 
ent.    In  the  nodular  form  symptoms  are  often  absent. 

Diagnosis.— Difficult  to  distinguish  from  fibromata.  Where 
frequent  and  increasing  hemorrhages  are  associated  with  a 
hard  and  enlarged  uterus,  adenomyoma  may  be  suspected. 
In  the  subperitoneal  and  ligamentous  variety  accurate  diag- 
nosis is  impossible  except  at  operation.  Vaginal  examination 
shows  a  cervix  nearly,  if  not  quite,  normal  and  a  hard  enlarged 
uterus  generally  fixed  by  adhesions  as  the  disease  advances. 

Treatment. — Hysterectomy  is  indicated.  Myomectomy  is 
not  practical  on  account  of  the  diffuse  nature  of  the  growth. 

UTERINE  POLYP. 

Definition. — A  pedunculated  tumor  attached  to  the  uterine 
mucous  membrane. 


TUBERCULOSIS  OF  THE   UTERUS  Ql 

Pathology. — Distinction  should  be  made  from  the  peduncu- 
lated submucous  fibroids  which  grow  from  the  muscular 
wall  of  the  body  of  the  uterus.  The  mucous  polypi  are  devel- 
oped from  the  mucous  membrane,  are  of  soft,  pulpy  consist- 
ency, extremely  vascular,  and  have  the  same  microscopic 
structure  as  the  mucous  membrane  from  which  they  are 
derived. 

Etiology. — Unknown. 

Symptoms. — These  are  hemorrhage,  dysmenorrhea,  leu- 
corrhea,  endometritis,  and  sterility. 

Diagnosis. — When  the  polypus  presents  at  the  external  os 
it  may  be  readily  recognized  as  a  small,  highly  vascular 
growth,  bright  red  in  color,  and  soft  in  consistency.  When 
not  seen  at  the  os  the  cervical  canal  must  be  dilated  and 
explored.  From  pedunculated  fibroids  the  diagnosis  is  made 
by  the  small  size,  soft  consistency  and  extreme  vascularity. 

Treatment. — Operative  removal.  Dilate  the  cervix  if 
necessary,  grasp  the  polyp  with  a  heavy  pair  of  forceps, 
twisting  the  pedicle  until  the  tumor  comes  away.  Ligation 
and  division  of  the  pedicle  may  be  practised  when  the  tumor 
is  within  easy  reach.  After  the  removal  of  the  polyp  the  uterus 
should  be  curetted  and  packed  with  gauze. 


TUBERCULOSIS  OF  THE  UTERUS. 

Primary  tuberculosis  of  the  uterus  is  rarely  encountered. 
The  cervix  may  be  involved  independently  of  the  body,  but 
origin  at  the  fundus  with  extension  downward  is  more  com- 
mon.  Ulceration  begins  in  the  endometrium,  all  tissues  of  the 
uterus  being  eventually  involved.  Secondary  tuberculosis  of 
the  uterus  is  not  uncommon  in  general  tuberculous  infection. 

Symptoms. — None  that  are  pathognomonic.  There  is 
usually  a  profuse  and  purulent  leucorrhea,  with  occasional 
hemorrhage.  Tubercle  bacilli  may  be  found  in  the  granula- 
tion tissue  discharged,  or  removed  by  the  curette. 


92  DISEASES  OF  THE  FALLOPIAN  TUBES 

Diagnosis. — Difficult  to  make  from  cancer  except  when  the 
tubercle  bacilli  are  found. 

Treatment. — High  amputation  of  the  cervix  or  complete 
removal  of  the  uterus,  dependent  on  the  extent  of  the  disease. 

SUBINVOLUTION  OF  THE  UTERUS. 

Definition. — Incomplete  involution  of  the  uterus  following 
miscarriage  or  labor. 

Pathology. — The  endometrium  is  thickened  by  glandular 
hypertrophy,  the  muscle  cells  are  enlarged,  the  lymphatics 
distended,  and  the  bloodvessels  engorged. 

Symptoms. — Premature  return  of  menstruation  or  menor- 
rhagia,  dull,  heavy  feeling  in  the  pelvis,  backaches,  and 
leucorrhea. 

Diagnosis. — On  examination  the  uterus  is  found  to  be 
large,  soft,  low  down  in  the  pelvis  and  often  retroposed. 

Treatment. — Displacements  should  be  reduced  and  a  proper 
pessary  inserted.  Recent  cases  yield  readily  to  the  depleting 
action  of  boroglyceride  or  ichthyol  tampons  three  times  a 
week,  with  prolonged  hot  vaginal  douches  at  bedtime.  Ergot, 
though  generally  recommended  in  subinvolution,  should  not 
be  given  to  nursing  mothers  because  of  its  tendency  to  dimin- 
ish or  stop  the  flow  of  milk.  Curettage  is  indicated  in  cases 
of  long  standing. 


CHAPTER    IX. 

DISEASES  OF  THE  FALLOPIAN  TUBES. 

Abnormalities  are  of  infrequent  occurrence,  and  seldom 
call  for  treatment.  Congenital  absence  of  one  or  both  tubes, 
defective  development,  accessory  fimbriated  end,  and  hernia 


SALPINGITIS 


93 


of  the  tube,  either  inguinal,  femoral,  or  obturator,  have  been 
observed. 

The  most  important  pathological  conditions  met  with  are  the 
inflammations  which  are  usually  due  to  microorganisms,  of 
which  the  gonococcus  is  the  most  common.  The  acute 
exanthemata  (scarlet  fever,  diphtheria,  measles,  etc.)  are 
responsible  for  some  cases. 

Fig.  25 


Congenital  absence  of  the  right  tube  and  ovary:  A,  uterine  canal  divided  at  inter- 
nal os;  B,  right  horn  of  uterus;  C,  fundus;  D,  left  cystic  ovary  and  pyosalpinx. 


SALPINGITIS. 

Definition. — An  inflammation  of  the  tube,  either  acute  or 
chronic. 

Pathology. — The  tubal  tissues  become  swollen,  the  result 
of  small-cell  infiltration;  the  tube,  as  a  whole,  thickens  with 
exaggeration  of  its  normal  ''kinks."  The  distal  end  may 
become  closed,  forming  a  club-shaped  tube.  When  the  in- 
flammation runs  into  the  purulent  stage  the  fimbriated  end 
is  usually  closed  by  adhesions,  the  pus  accumulates  in  the 
tube  and  a  pyosalpinx  is  produced.  In  cases  of  long  standing 
the  pus  is  absorbed  or  degenerates  into  a  thin,  watery  fluid, 
forming  a  hydrosalpinx.      Adhesions  may  or  may  not  form 


94 


DISEASES  OF  THE  FALLOPIAN   TUBES 


between  the  tube  and  neighboring  viscera.  If  a  pyosalpinx 
adhering  to  a  cystic  ovary  perforates  at  the  point  of  adhesion, 
pus  may  escape  into  one  of  the  cysts  and  a  tubo-ovarian 
abscess  result.  Perforation  and  evacuation  may  take  place  into 
the  bladder  or  intestines.  Occasionally  a  pus  tube  drains 
spontaneously  by  way  of  the  uterine  cavity  and  vagina.  Pus 
infection  in  the  tube  usually  leads  to  complete  destruction 
of  its  normal  epithelium,  and  the  mucosa  and  muscular  coat 
are  eventually  represented  by  fibrous  tissue. 


Fio.  26 


Pyosalpinx. 

Complete  regeneration  and  restoration  of  function  often 
occurs  in  mild  infections,  the  abdominal  end  of  the  tube 
remaining  patent. 

Etiology. — Salpingitis  is  usually  caused  by  invading  micro- 
organisms from  the  uterus.  Wertheim  gives  the  following 
percentages,  drawn  from  376  cases: 

Per  cent. 

Gonococci 20.2 

Streptococci  or  staphylococci 13.2 

Pneumococci 1.8 

Bacillus  coli 0.7 


SALPINGITIS 


95 


Symptoms. — Following  a  septic  or  gonorrheal  infection  in 
the  uterus  or  vagina  the  patient  complains  of  pain  in  the 
region  of  the  tube,  aggravated  by  exercise  or  long  standing. 
Where  the  condition  is  acute,  elevation  of  temperature  and 
pulse  are  observed,  with  occasionally  nausea  and  vomiting. 
The  symptoms  of  chronic  salpingitis  are  those  referable  to 
adhesions  and  congestion,  the  most  prominent  being  con- 
tinuous pain  in  the  region  of  the  tube.  Menorrhagia  and 
dysmenorrhea  are  fairly  constant  symptoms. 

Diagnosis. — From  the  history  is  elicited  the  fact  of  a  recent 
septic  or  gonorrheal  infection.  Vaginal  examination  dis- 
closes marked  tenderness  and  resistance  in  the  lateral  or 
posterior  fornix,  according  to  the  acuteness  of  the  disease. 
In  chronic  salpingitis  the  thickening  of  the  tube  may  be  felt. 
Where  a  pyosalpinx  or  tubo-ovarian  abscess  has  formed  it  is 
possible  to  map  out  a  distinct  tumor  by  the  side  of  or  posterior 
to  the  uterus.  In  right-sided  salpingitis  it  is  important  to 
distinguish  from  appendicitis,  and  the  following  summary  of 
respective  symptoms  may  be  of  service : 


Acute  Salpingitis. 

Previous  gonorrheal  or  puerperal  infec- 
tion. 

Gradual  onset  of  pain,  dull,  continuous, 
and  radiating  in  character. 

Elevation  of  temperature  and  pulse 
slight  and  variable. 

Muscular  rigidity  absent  unless  perito- 
nitis exists. 

Vaginal  examination  always  painful. 

Nausea  and  vomiting  unusual. 


Acute  Appendicitis. 
No  previous  local  disturbances. 

Sudden  onset,  pain  acute  and  localiz- 
ing in  right  iliac  region. 

Elevation  of  temperature  and  pulse 
marked  and  constant. 

Muscular  rigidity  pronounced  on  right 
side  of  abdomen. 

Vaginal  examination  seldom  painful. 

Nausea  and  vomiting  usual. 


The  appendix  is  involved  secondarily  in  about  20  per  cent, 
of  purulent  infections  of  the  right  appendages,  but  the  inflam- 
mation is  seldom  acute. 

Treatment. — Varies  materially  according  to  the  stage  of  the 
disease. 

Acute  Salpingitis. — Absolute  rest  in  bed,  prolonged  hot 
vaginal  douches,  and  hot-water   bag  to  the  affected  side. 


96  DISEASES  OF  THE  FALLOPIAN  TUBES 

Morphine  internally  or  opium  suppositories  when  the  pain 
is  severe.  The  bowels  should  be  kept  well  opened,  and 
frequent  vaginal  examination  is  to  be  avoided. 

Pyosalpinx. — Same  as  for  acute  salpingitis  while  in  the 
acute  stage.  If  the  abscess  shows  a  tendency  to  constant 
enlargement,  an  incision  in  the  posterior  vaginal  fornix  should 
be  made  and  the  tube  opened  and  drained.  After  subsidence 
of  the  acute  symptoms,  operative  removal  of  the  tube  will 
often  be  necessary. 

Tubo-ovarian  Abscess. — Here  resolution  seldom  takes  place 
and  operative  measures  are  the  best  treatment.  Evacuation 
and  drainage  by  the  vaginal  route  offers  reasonable  hope  of 
cure,  and  is  always  advisable  where  interference  during  the 
acute  stage  becomes  necessary,  or  when  there  is  a  large  accu- 
mulation of  pus.  Ablation  of  the  diseased  appendages  is  the 
accepted  radical  treatment,  and  may  be  performed  by  either 
the  vaginal  or  abdominal  route. 

Chronic  Salpingitis. — Where  the  symptoms  are  alone  due  to 
the  inflammation  in  the  tube,  ichthyol  (10  per  cent.)  and 
glycerin  tampons  to  the  posterior  fornix  three  times  a  week 
do  much  to  improve  the  condition.  Extensive  disease  of  the 
tube  with  adhesions  usually  calls  for  radical  treatment  by 
operation,  necessitating  removal  of  the  tube  or  the  separation 
of  adhesions  with  resection  of  the  diseased  portion.  Every 
effort  should  be  made  to  conserve  the  function  of  the  tube  and 
resection,  rather  than  complete  removal,  practised  wherever 
it  offers  reasonable  hope  of  leaving  a  patent  canal. 

INFECTIOUS  GRANULOMA. 

Definition. — An  infection  of  the  tube,  either  syphilitic, 
actinomycotic  or  tuberculous,  of  which  only  the  last  is  of 
practical  importance. 

Pathology. — The  Fallopian  tube  is  the  most  common  seat 
of  tuberculosis  of  the  genital  tract.  It  may  be  either  primary 
or  secondary  to  peritoneal  tuberculosis.     The  changes  pro- 


DISEASES  OF  THE  OVARY  97 

duced  are  quite  marked;  the  mucosa  shows  a  round-cell 
infiltration  with  giant  cells  and  bacilli,  the  whole  tube  is 
thickened,  beaded,  and  in  the  late  stages  contains  pus  and 
caseous  debris. 

Etiology. — Infection  by  the  tubercle  bacilli.  The  source  of  in- 
vasion is  not  clear,  probably  through  the  blood  by  metastasis. 

Symptoms. — Early  cases  show  few  symptoms.  Menstrua- 
tion is  usually  more  frequent  and  profuse.  Pain  is  not  con- 
stant, and  may  be  elicited  only  on  examination.  As  the 
disease  becomes  advanced,  local  symptoms,  the  result  of 
enlargement  of  the  tube,  appear. 

Diagnosis. — Vaginal  examination  may  show  a  thickened, 
nodular  tube,  or,  where  there  is  much  distention  with  pus,  a 
distinct  tumor.  Constant  elevation  of  temperature  and  pulse 
are  present  in  advanced  cases.  The  presence  of  tuberculosis 
elsewhere  in  the  body  may  aid  in  the  diagnosis. 

Treatment. — Operation:  Removal  by  abdominal  section 
where  practical,  but  in  advanced  cases,  with  extensive  adhe- 
sions and  secondary  pockets  of  pus,  the  operation  will  give 
the  best  results  if  not  carried  beyond  the  exploratory  stage  as 
in  general  tuberculous  peritonitis. 

Neoplasms  of  the  Fallopian  tubes  are  of  rare  occurrence. 
Papilloma,  fibromyoma,  lipoma,  cystoma,  carcinoma,  and 
sarcoma  have  been  met  with.  They  are  seldom  diagnos- 
ticated before  operation,  and  the  treatment  is  removal. 

Tubal  Gestation. — See  Ectopic  Gestation,  p.  103. 


CHAPTER  X. 

DISEASES  OF  THE  OVARY. 

As  the  result  of  maldevelopment  one  or  both  ovaries  may  be 
absent,  or  show  only  a  rudimentary  development.  Occasionally 
a  third  ovary  is  present:  supernumerary  ovary. 

7 


98  DISEASES  OF  THE  OVARY 


OVARITIS. 


Definition. — An  inflammation  of  the  ovary,  acute  or  chronic. 

Pathology. — In  the  acute  form  the  ovary  is  sHghtly  enlarged, 
there  is  a  proliferation  in  its  connective-tissue  elements  and  the 
peripheral  follicles  are  distended  with  a  turbid  fluid  or  pus. 

In  the  chronic  variety  the  ovary  may  be  small  and  cystic, 
there  is  destruction  of  the  follicles,  and  a  cirrhotic  condition 
develops,  giving  rise  to  marked  impairment  of  function.  In 
passive  congestion  of  the  ovary  slight  enlargement  is  present. 

Etiology. — Gonorrhea,  septic  infection  from  adjacent  tis- 
sues, acute  febrile  diseases,  mumps,  and  pelvic  peritonitis. 
Prolapse  of  the  ovary  frequently  gives  rise  to  a  condition  of 
chronic  inflammation. 

Symptoms. — Pelvic  pain,  dysmenorrhea,  menorrhagia,  and 
dyspareunia. 

Diagnosis. — On  vaginal  examination  a  large,  tender  ovary 
is  found  often  prolapsed  and  lying  in  the  posterior  fornix.  It 
glides  under  the  finger  and  gives  acute  pain  when  pressed. 
Accompanying  disease  of  the  tube  often  makes  a  differential 
diagnosis  difficult.  It  is  well  to  remember  that  a  certain 
degree  of  congestion  and  enlargement  in  the  ovary  is  normal 
at  the  time  of  ovulation. 

Treatment. — Ichthyol  (10  per  cent.)  and  glycerin  tampons 
three  times  a  week,  with  appropriate  treatment  of  the  bowels. 
In  long-standing  cases  operative  removal  may  be  the  only 
means  of  giving  relief. 

DISPLACEMENTS  OP  THE  OVARY. 

Varieties. — The  ovary  may  be  found  lying  In  the  inguinal 
or  femoral  canal.    Prolapse  is  the  most  frequent  displacement. 

Prolapse  of  the  Ovary. — Pathology. — The  ovary  occupies  a 
much  lower  level  in  the  pelvis  than  normal,  due  to  relaxation  of 
the  ovarian  and  infundibulopelvic  ligaments.    These  may  be 


TUMORS  OF  THE  OVARY  99 

abnormally  lax,  or  become  stretched  by  increased  weight  of 
the  ovary.  Adhesions  often  form,  fixing  the  ovary  in  its 
abnormal  position. 

Etiology. — Congenitally  long  and  lax  ligaments,  or  their 
subinvolution  after  parturition.  Gravity  acting  on  an  enlarged 
heavy  ovary,  and  posterior  displacements  of  the  uterus,  in 
which  the  ovary  follows  the  fundus  backward. 

Symptoms. — Radiating  pains  in  the  pelvis,  pain  on  defeca- 
tion and  coitus,  reflex  nervous  symptoms. 

Diagnosis. — Bimanual  examination  fails  to  locate  the  ovary 
in  its  normal  position,  and  a  small,  firm,  tender  body  low 
down  on  the  broad  ligament  or  in  the  posterior  fornix  is 
found.  Rectal  examination  will  often  give  a  clearer  picture, 
and  help  in  dififerentiating  from  fecal  concretions,  a  frequent 
source  of  error. 

Treatment. — Displacements  of  the  uterus,  when  corrected, 
often  bring  the  ovary  into  normal  position.  Boroglyceride 
tampons  will  aid  in  the  involution  of  the  ligaments,  relieve  the 
ovarian  congestion,  and  often  give  marked  relief.  When  the 
ovary  is  fixed  by  adhesions  operation  must  be  resorted  to,  the 
ovary  restored  to  its  normal  position,  and  the  relaxed  ovarian 
ligament  shortened. 


TUMORS  OF  THE  OVARY. 

The  most  common  tumors  of  the  ovary  are  the  cystomata. 
Sarcomata  and  carcinomata  are  less  frequently  encountered. 
Stander  estimates  their  relative  frequency  as  follows : 

Per  cent. 

Cystadenoma ,.      69.49 

Carcinoma 13.56 

Sarcoma 6.78 

The  subject  of  ovarian  tumor  is  exceedingly  complex,  and 
very  difficult  to  treat  in  the  abbreviated  form  necessary  to  a 
work  of  this  character. 


100  DISEASES  OF  THE  OVARY 

Pathology. — Probably  the  best  classification  is  that  of 
Pf  annenstiel : 

Class  A.  Tumors  arising  from  the  parenchyma  of  the 
ovary. 

Class  B.  Tumors  arising  from  the  stroma. 

Class  C.  Mixed  tumors. 

Class  A  consists  of:  1.  The  simple  serous  cysts — usually 
monolocular,  containing  a  sero-albuminous  fluid  and  lined 
with  a  single  layer  of  columnar  epithelial  cells. 

2.  Adenomata,  the  most  common  form  of  cystic  tumor  of 
the  ovary,  are  composed  of  cyst  and  pedicle.  The  pedicle  is 
formed  by  a  drawing  out  of  the  broad  ligament  during  the 
growth  of  the  tumor.  The  cyst  may  eventually  attain  enor- 
mous size,  is  multilocular,  and  the  contained  fluid,  thick  and 
tenacious,  is  secreted  by  the  lining  epithelium. 

3.  Papillomata,  which  are  characterized  by  papillary  pro- 
jections of  connective  tissue  covered  with  columnar  epithelium, 
may  be  situated  either  on  the  surface  of  the  tumor  or  inside 
the  cyst.    The  fluid  contents  are  thin  and  serous. 

4.  Dermoids  and  Teratomata. — Dermoids  arise  from  the 
germ  layers,  and  are  usually  cystic  in  character.  They  con- 
tain relics  of  ectodermic  origin  (skin,  hair,  teeth,  bones,  etc.). 
The  teratomata  are  solid  dermoids,  usually  malignant  in 
nature. 

Class  B  consists  of:  1.  Non-malignant  solid  tumors — 
myoma,  fibroma.  They  may  involve  the  whole  ovary,  or  only 
spring  from  it  by  a  pedicle,  and  are  usually  of  small  size. 

2.  Malignant  tumors  frequently  complicate  cystic  degenera- 
tion and  also  arise  independently  as  primary  sarcoma  or 
carcinoma.  The  angiomata,  enchondromata,  and  myxomata 
are  rare.    Tuberculosis  is  occasionally  seen. 

3.  Parovarian  cysts  are  unilocular  tumors  developed  from 
the  parovarium,  are  thin-walled,  and  contain  a  thin,  watery 
fluid.  They  are  commonly  small,  but  may  attain  large  size, 
cubical  or  squamous  cells  usually  compose  the  lining  mem- 
brane; ciliated  cells  are  sometimes  found. 


TUMORS  OF  THE  OVARY 


101 


Class  C  consists  of :  The  association  of  dermoids,  sarcomata, 
or  carcinomata,  with  the  multilocular  adenomatous  forms. 


Fig.  27 


Hair  and  teeth  removed  from  a  dermioid  cyst  of  the  ovary. 


Symptoms. — These  are  in  direct  proportion  to  the  size  of 
the  tumor,  and  rarely  become  acute,  except  in  ovarian  cysts, 
when  torsion  of  the  pedicle,  suppuration,  and  septic  or 
gonorrheal  infection  occurs.  There  is  then  pain  with  eleva- 
tion of  temperature  and  pulse  due  to  local  peritonitis. 

Diagnosis. — The  larger  the  tumor  the  more  certain  become 
the  diagnosis.  The  small  and  medium-sized  tumors  are  best 
made  out  by  bimanual  examination,  which  discloses  a  tense, 
rounded,   hard,  or  fluctuating  mass  in  the  ovarian  region. 


102 


DISEASES  OF  THE  OVARY 


The  uterus,  displaced  downward  and  to  one  side,  may  usually 
be  mapped  out  distinct  from  the  tumor. 

The  large  tumors  are  generally  cystic  and  easily  recognized. 
Vaginal  examination  shows  the  cervix  depressed  and  the  whole 
pelvis  filled  by  a  tense  fluctuating  mass.  On  abdominal 
examination  the  abdomen  is  seen  more  or  less  distended  by  a 
lateral  or  uniform  swelling;  palpation  gives  marked  fluctua- 
tion, while  on  percussion  there  is  dulness  over  the  entire 
tumor  unaffected  by  changes  in  position  on  the  part  of  the 
patient.  Confusion  in  diagnosis  between  ovarian  cysts  and 
free  fluid  in  the  peritoneal  cavity  (ascites)  may  arise,  and  the 
following  tabulation  by  Findley  will  aid  in  distinguishing 
between  the  two: 


Ascites. 

Development  Rapid. 

Inspection  of  abdomen,  dorsal  position. 

Flattened  anteriorly  with  bulging  in  the 

flanks. 
Umbilicus  prominent. 

Percussion. 

Dulness  in  flanks. 
TjTnpany  in  median  area. 
Change  in  area  of  dulness  with  change  in 
position  of  patient. 

Palpation. 
No  tumor  outline  can  be  distinguished. 


Large  Ovarian  Cyst. 

Development  Slow. 

Inspection  of  abdomen. 

Rounded  anteriorly,  flat  in  the  flanks. 

Umbilicus  not  prominent. 

Percussion. 

Dulness  over  abdominal  prominence. 

Tympany  in  flanks. 
Such  change  absent. 

Palpation. 
Tumor  can  be  outlined. 


Treatment. — The  treatment  of  all  ovarian  tumors  should 
be  removal  by  operation,  where  no  contra-indications  exist. 
The  presence  of  the  tumor  per  se  may  not  be  incompatible 
with  perfect  health,  but  there  is  no  tendency  to  spontaneous 
cure  and  serious  complications  often  arise  when  least  expected. 


CHAPTER  XI. 

ECTOPIC  GESTATION. 

Definition. — Pregnancy  outside  the  uterine  cavity. 

Pathology. — Impregnation  of  the  ovum  may  normally  occur 
at  any  point  in  its  passage  from  the  ovary  to  the  uterine  cavity, 
but  arrest  of  the  fertiUzed  ovum  before  reaching  the  uterine 
cavity  is  pathological,  and  constitutes  the  condition  known  as 
extra-uterine  gestation. 

When  permanent  arrest  occurs  it  is  designated  as  primary, 
and  when  change  of  the  position  accompanies  further  develop- 
ment it  is  known  as  secondary. 

Kelly  gives  the  following  table  to  show  the  changes  which 
the  primary  form  may  undergo: 

Primary  Forms.  Secondary  Farms. 

'  r  Intra-uterine. 

Interstitial         .      .      .      •      •      •      •      may  become  <  Abdominal  (fetus  dies). 

(  Intraligamentary  (fetus  dies). 

f  Mole  (fetus  dies). 

I  Abortion  (fetus  dies). 

-  I  Tubo-abdominal. 

Tubal may  become  ,  m  u 

•^""'^ I  Tubo-ovanan. 

I  Abdominal. 

[  Intraligamentary  (fetus  dies). 

Ovarian may  become  \  Abdominal  (fetus  dies). 

Interstitial  and  ovarian  implantations  are  rare;  tubal  is 
common. 

In  all  the  primary  forms  death  of  the  fetus,  or  early  rupture, 
is  the  rule,  while  of  the  secondary  forms  the  intra-uterine, 
tubo-abdominal,  tubo-ovarian,  and  abdominal  frequently  go 
on  to  term. 

When  the  death  of  the  fetus  takes  place,  termination  in 
ab.sorption,  suppuration,  or  its  retention  in  a  mummified  con- 
dition result.    When  rupture  occurs  the  fetus  usually  dies  and 

(103) 


104 


ECTOPIC  GESTATION 


a  pelvic  hematocele  develops.  Rarely  the  extra-uterine  gesta- 
tion may  be  associated  with  intra-uterine  gestation,  and  cases 
of  multiple  tubal  pregnancy  have  been  reported,  where  each 
tube  contained  an  ovum  (twin  tubal  gestation)  and  where  one 
tube  contained  two  ova  (tubal  twin  pregnancy)  (Fig.  28). 


Fig.  28 


Tubal  twin  pregnancy.    Ruptured. 


are 


Etiology. — The  causes  of  extra-uterine  pregnancy 
still  surrounded  with  obscurity.  The  predisposing  causes, 
interfering  with  the  passage  of  the  fructified  ovum  to  the 
uterine  cavity,  may  be  want  of  development,  abnormal  length 
or  permanent  contraction  of  the  tube,  or  disease  of  its  mucosa. 

Symptoms. — Cessation  of  menstruation  accompanied  by 
other  signs  of  pregnancy  are  the  early  symptoms.  Later 
pelvic  pain  develops,  there  is  irregular  hemorrhage,  more  or 
less  profuse,  from  the  uterus,  and  occasionally  the  discharge  of 


DIAGNOSIS  AFTER  RUPTURE 


105 


a  decidual  cast  is  observed.  With  rupture  there  is  sudden 
severe  pain  in  the  region  of  the  tube,  and  symptoms  of  internal 
hemorrhage  appear,  varying  with  the  severity  of  the  bleeding, 
Diagnosis  in  General. — The  two  most  important  factors  in 
establishing  a  diagnosis  are  the  history  of  the  case  and  the 
physical  examination.  The  signs  vary  with  the  period  of 
gestation,  ruptured  or  unruptured  condition  of  the  sac,  and 
with  a  dead  or  living  fetus 


Fig.  29 


Tubal  pregnancy  removed  before  rupture. 


Diagnosis  before  Rupture. — Cessation  of  menstruation,  one 
or  more  periods  having  been  missed,  or  the  patient  may  be 
only  a  few  days  overdue.  Nausea  and  other  early  signs  of 
pregnancy  may  be  present. 

On  vaginal  examination  a  soft,  elastic  ovoid  tumor  is  found 
to  one  side  of  the  uterus.  This  increases  progressively  in  size 
unless  death  of  the  fetus  takes  place.  The  uterus  is  slightly 
enlarged,  and  may  throw  off  a  decidual  cast. 

Diagnosis  after  rupture  depends  on  the  sudden  onset  of 
acute  symptoms.  Severe  pain  in  the  pelvis,  elevation  of 
pulse,  subnormal  temperature,  blanched  anxious  expression, 


106  ECTOPIC  GESTATION 

and  collapse.  Vaginal  examination  fails  to  reveal  a  tumor 
lying  by  the  side  of  the  uterus,  which  may  have  been  previously 
diagnosticated.  If  the  internal  hemorrhage  is  profuse, 
bulging  in  the  posterior  vaginal  fornix  and  dulness  in  both 
flanks,  denoting  free  fluid  in  the  peritoneal  cavity,  can  be  made 
out.  A  posterior  vaginal  incision  into  the  peritoneal  cavity 
often  gives  confirmatory  evidence  by  liberating  free  blood, 
although  it  is  rarely  necessary  to  establish  a  diagnosis.  The 
patient  may  die,  never  rallying  from  the  collapse,  or  slowly 
recover.  A  succession  of  hemorrhages  at  varying  intervals 
and  increasing  in  severity  is  not  an  uncommon  occurrence. 
The  possibility  of  hemorrhage  into  an  ovarian  cyst  should  be 
borne  in  mind,  as  this  condition  may  occasionally  closely 
resemble  tubal  pregnancy. 

Treatment. — In  unruptured  cases  the  treatment  is  opera- 
tive removal  as  soon  as  the  diagnosis  is  established. 

Ruptured  cases  with  severe  symptoms  call  for  immediate 
operation.  If  the  symptoms  are  slight  and  the  patient  recover- 
ing from  the  initial  shock,  operation  may  be  deferred  and 
further  improvement  awaited. 

When  operation  is  performed  early  to  check  the  hemor- 
rhage, it  should  be  by  the  abdominal  route  and  consist  in 
rapid  ligation  of  bleeding  vessels  with  removal  of  the  products 
of  gestation,  blood,  and  blood  clots.  The  tube  may  or  may 
not  call  for  removal. 

Late  operation  for  the  removal  of  the  debris  where  active 
hemorrhage  has  ceased  may  be  performed  by  the  vaginal 
route,  and  will  be  considered  under  pelvic  hematocele.  Stimu- 
lation is  always  indicated :  Strychnine  sulphate,  -f-^  grain,  given 
hypodermically,  and  repeated  every  two  hours  as  long  as 
necessary,  and  intravenous  infusion  of  normal  saline  solution, 
where  the  shock  is  severe. 


CHAPTER  XII, 

DISEASES  OF  TPIE  PARAMETRIUM. 

PELVIC  PERITONITIS. 

Definition. — Inflammation  of  the  pelvic  peritoneum,  either 
acute  or  chronic. 

Pathology. — Following  the  primary  injection  of  the  peri- 
toneum, serous  effusion  and  the  formation  of  plastic  exudate 
soon  develop,  causing  adhesions  between  the  uterus,  intestines, 
omentum,  and  appendages.  These  may  be  slight  and  transi- 
tory in  character,  or  dense  and  permanent,  according  to  the 
nature  of  the  infection. 

Etiology. — Generally  caused  by  microorganisms.  Fre- 
quently secondary  to  diseases  of  the  appendages,  especially 
gonorrheal  salpingitis. 

The  symptoms  of  acute  pelvic  peritonitis  manifest  themselves 
by  elevation  of  temperature  and  pulse,  and  sharp,  shooting 
pains  in  the  pelvis.  Constipation  is  usually  present.  The  dor- 
sal position  is  the  one  of  choice,  the  patient  lying  with  both 
legs  drawn  up  to  relieve  the  pain. 

The  symptoms  of  chronic  pelvic  peritonitis  are  dull,  con- 
tinuous pain  in  the  pelvis,  aggravated  by  exercise,  coitus,  and 
vaginal  examination.  Menorrhagia,  dysmenorrhea,  and 
backache  are  special  symptoms. 

Diagnosis. — A  careful  vaginal  examination  should  be  made 
to  decide  if  possible  the  condition  of  the  appendages.  In  the 
acute  cases,  on  account  of  the  extreme  pain  it  causes,  this 
reveals  nothing  usually  beyond  a  hot,  tender  vagina  with 
pulsating  vessels  at  the  fornices.  After  exudation  has  occurred 
a  more  or  less  distinct  bulging  may  be  felt  in  the  posterior  for- 
nix, and  if  absorption  does  not  take  place  and  the  case  goes  on 
to  abscess  formation,  this  bulging  assumes  the  form  of  a  hard, 
tense  tumor  obliterating  the  fornix  and  producing  marked 

(107) 


108  DISEASES  OF  THE  PARAMETRIUM 

bulging  of  the  posterior  vaginal  wall.  The  mobility  of  the 
uterus  is  greatly  restricted. 

In  chronic  cases  an  obscure  thickening  is  felt  at  the  fornices 
and  adhesion  bands  may  be  made  out  in  the  cul-de-sac.  The 
uterus  is  often  found  in  a  retroposed  position,  and  its  mobility 
is  generally  more  or  less  restricted. 

Treatment  of  acute  pelvic  peritonitis  should  be  by  absolute 
rest  in  bed,  saline  laxatives,  prolonged  hot  vaginal  douches, 
and  opiates,  when  indicated,  for  the  pain.  If  the  case  pro- 
ceeds to  suppuration,  a  posterior  vaginal  incision  to  liberate 
the  pus  should  be  made  (see  under  Pelvic  Abscess).  In  the 
chronic  form  ichthyol  (10  per  cent.)  and  glycerin  tampons, 
three  times  a  week,  will  give  marked  relief.  When  the  adhe- 
sions are  extensive,  and  displacement  of  the  uterus  with 
diseased  appendages  exist,  operative  treatment  must  be  con- 
sidered (see  Salpingitis,  page  93). 


PELVIC  HEMATOCELE. 

Definition. — Pelvic  hematocele  is  more  properly  a  symptom 
of  some  previous  pathological  condition  existing  in  the  pelvic 
organs,  generally  the  tubes.  A  collection  of  blood  in  the  pelvic 
peritoneum  or  connective  tissues. 

Pathology. — The  hemorrhage  is  most  often  intraperitoneal, 
the  result  of  some  disturbance  in  the  development  of  an  ectopic 
gestation.  An  extraperitoneal  form  is  recognized,  but  is  of 
infrequent  occurrence. 

Etiology. — The  chief  cause  is  extra-uterine  gestation. 

Symptoms. — When  developing  suddenly  there  is  severe  pain 
with  symptoms  of  internal  hemorrhage  (see  Ectopic  Gesta- 
tion, page  103). 

Diagnosis. — Previous  signs  of  internal  hemorrhage,  with, 
on  vaginal  examination,  a  bulging  tumefaction  in  the  pelvis 
posterior  or  lateral  to  the  uterus.  This  is  soft  and  fluctuating 
in  character  and  only  slightly  tender  on  pressure. 


PELVIC  ABSCESS  109 

Treatment. — When  seen  early,  as  a  symptom  of  ectopic 
gestation,  abdominal  section  for  the  primary  condition  may  be 
indicated.  In  late  cases,  when  the  initial  shock  is  past,  the 
patient  recovering,  and  no  further  hemorrhages  have  occurred, 
absorption  is  the  favorable  termination  to  be  hoped  for,  the 
treatment  being  rest  in  bed,  prolonged,  hot  vaginal  douches, 
and  stimulants  when  indicated.  If  suppuration  occurs,  the 
treatment  becomes  that  of  pelvic  abscess. 

PELVIC  ABSCESS. 

Definition. — An  intrapelvic  suppuration  in  the  region  of  the 
uterus. 

Pathology. — The  infection  begins  usually  as  a  localized 
peritonitis  resulting  from  an  invasion  by  any  of  the  pus  pro- 
ducing microorganisms.  These  may  gain  entrance  to  the 
pelvic  peritoneum  through  the  Fallopian  tube  as  in  gonor- 
rheal infection,  or  through  the  uterine  wall  and  parametrium 
by  the  lymphatics,  as  in  streptococcus  infection.  Adhesions 
form  in  advance  of  the  suppuration ;  plastic  exudate  is  thrown 
out,  forming  a  thick  abscess  wall.  As  suppuration  advances 
extension  takes  place  in  all  directions,  but  gravity  favors  the 
posterior  vaginal  fornix — the  most  frequent  seat  of  spon- 
taneous rupture. 

Recovery  may  take  place  in  one  of  two  ways.  Small  accu- 
mulations of  pus  may  undergo  absorption,  while  in  large 
abscesses  evacuation  and  subsequent  drainage  are  established 
by  spontaneous  rupture  into  the  vagina,  rectum,  or  an  adjacent 
coil  of  intestines.  Rupture  into  the  free  peritoneal  cavity 
rarely  occurs  except  as  the  result  of  traumatism. 

Etiology. — Of  the  microorganisms  causing  pelvic  sup- 
puration, the  gonococcus,  streptococcus,  and  colon  bacillus 
are  most  frequently  encountered.  The  gonococcus  travels 
along  the  mucous  membrane  of  the  tube,  gaining  access  to  the 
pelvic  peritoneum  through  the  fimbriated  opening;  the  staphy- 
lococcus passes  through  the  uterine  wall  and  parametrium  by 


110  DISEASES  OF  THE  PARAMETRIUM 

the  lymphatics;  the  colon  bacillus  by  direct  migration  through 
the  intestinal  walls.  Gonorrheal  infection  is  most  frequently 
secondary  to  gonorrhea  of  the  tubes,  while  streptococcus  infec- 
tion most  often  follows  in  the  wake  of  a  carelessly  conducted 
puerperium  or  a  criminally  induced  abortion. 

Symptoms. — These  are  acute  during  the  actual  formation 
of  pus,  and  more  severe  in  the  streptococcus  and  colon  bacil- 
lus infections  than  in  the  gonorrheal.  There  are  elevation  of 
the  temperature  and  pulse,  intense  pelvic  pain,  local  tender- 
ness, and  some  abdominal  distention.  The  effect  of  pus 
absorption  is  soon  felt,  and  symptoms  of  sepsis  arise  early. 
A  gradual  subsidence  of  the  acute  symptoms  may  leave  the 
patient  in  a  weak,  exhausted  condition,  running  a  low  tem- 
perature, with  continuous  pelvic  pain,  painful  defecation  and 
micturition,  and  a  purulent  vaginal  discharge.  Subsequent 
acute  exacerbations  may  occur,  extending  over  a  period  of 
years,  if  a  pus  focus  remains. 

Diagnosis. — From  the  history  of  the  case  the  source  of  the 
infection  may  usually  be  traced  to  a  previous  attack  of  gonor- 
rhea, or  a  septic  labor,  or  a  criminal  or  ordinary  abortion.  The 
temperature  and  pulse  run  a  characteristic  septic  course. 
Vaginal  examination  shows  the  uterus  elevated  toward  the 
symphysis  pubis  and  fixed,  while  posterior  to  the  cervix,  often 
obliterating  the  fornix  and  bulging  the  posterior  vaginal  wall, 
lies  a  hard,  dense,  at  times  fluctuating,  shapeless  mass,  ex- 
tremely tender  on  pressure.  In  the  chronic  stage  a  differen- 
tial diagnosis  from  impacted  fibroid  is  often  possible  only 
by  operation. 

Treatment  during  the  acute  stages  should  be  expectant  as 
long  as  the  patient's  condition  warrants  it.  Absolute  rest  in 
bed,  prolonged  hot  vaginal  douches,  hot  or  cold  applications 
to  the  abdomen,  free  catharsis,  and  morphine  when  indicated. 
When  the  abscess  steadily  increases  in  size  and  the  symptoms 
show  no  improvement,  operative  interference  is  imperative. 
The  simplest  method  is  evacuation  by  direct  incision  into  the 
abscess,  posterior  to  the  cervix,  with  subsequent  drainage 
by  gauze  or  rubber  tubing. 


CHAPTER  XIII. 

MENSTRUATION  AND  ITS  DISORDERS. 

NORMAL  MENSTRUATION. 

Normal  menstruation  is  a  cyclical  change  occurring 
monthly  in  the  female.  It  is  characterized  by  a  flow  of  blood 
from  the  uterine  cavity,  accompanying  which  is  an  exfoliation 
of  the  superficial  layers  of  its  mucosa.  Its  period  of  onset 
varies  in  different  countries,  being  earlier  in  warm  climates 
(ten  to  twelve  years)  and  later  in  cold  ones  (fifteen  to  seven- 
teen years) ;  the  average  onset  is  at  the  age  of  fourteen  years. 
Suspension  of  menstruation  occurs  during  pregnancy  and 
lactation.  Continuation  of  the  menses  is  seen  in  robust, 
healthy  women  up  to  the  time  of  the  menopause  (forty  to  fifty 
years).  Once  established,  menstruation  recurs  monthly  at 
intervals  of  twenty-eight  to  thirty  days,  the  duration  of  the 
flow  being  two  to  eight  days,  and  the  quantity  about  one 
ounce  per  day.  Constitutional  symptoms  in  normal  menstrua- 
tion should  be  absent,  except  a  slight  sense  of  weight  and  ful- 
ness in  the  pelvis  and  the  amount  of  blood  lost  should  not  be 
sufficient  to  cause  any  degree  of  weakness  or  debility.  The 
various  deviations  from  normal  menstruation  are  ofttimes  but 
symptoms,  and  will  be  considered  as  they  arise. 

PREMATURE  MENSTRUATION. 

Menstruation  may  occur  before  puberty,  and  is  then  pre- 
cocious. Cases  are  recorded  where  the  function  has  developed 
as  early  as  the  first  year.  In  most  of  these  cases  there  is  like- 
wise a  premature  general  and  sexual  development;  hair 
appears  on  the  pubes  and  in  the  axillae,  the  breasts  enlarge, 
and  the  generative  organs  undergo  marked  development. 

(Ill) 


112  MENSTRUATION  AND  ITS  DISORDERS 

Premature  menstruation  is  in  a  measure  hereditary,  but 
early  direction  of  attention  to  the  sexual  organs  by  the  associa- 
tion with  older  and  vicious  children  would  appear  to  be  an 
important  predisposing  element. 

The  treatment  should  be  directed  as  far  as  possible  toward 
removing  the  cause.  Local  irritation  tending  to  masturbation 
should  be  corrected,  nervous  excitement  avoided,  and  general 
rest  and  tonics  prescribed. 

DELAYED  MENSTRUATION. 

Delayed  menstruation  is  often  caused  by  tardy  development 
of  the  generative  organs,  the  flow  not  being  established  until 
the  seventeenth  to  nineteenth  year  of  life.  Heredity,  lack  of 
nutrition  and  proper  exercise  are  the  more  important  causa- 
tive factors.  In  the  management  of  these  cases  change  of 
occupation  and  suitable  hygienic  measures  will  generally 
suffice. 

VICARIOUS  MENSTRUATION. 

When  the  menstruation  is  absent  or  suppressed,  periodic 
vicarious  bleeding  sometimes  occurs  from  the  mucosa  of  the 
alimentary  or  respiratory  tracts,  ear,  and  nose,  or  from  an 
existing  raw  surface,  such  as  a  leg  ulcer. 

AMENORRHEA. 

Definition. — Absence  of  menstruation. 

Pathology. — Amenorrhea  exists  normally  during  pregnancy 
and  lactation;  pathologically  it  may  be  the  result  of  lack  of 
development  of  the  generative  organs.  The  uterus  and  ovaries 
may  be  absent  or  in  a  rudimentary  condition,  or  maldevelop- 
ment,  such  as  atresia  of  the  cervix,  vagina,  or  hymen,  may 
exist. 


MENORRHAGIA  113 

Etiology. — Delayed  puberty,  anemia,  chlorosis,  diabetes, 
malaria,  tuberculosis,  and  acute  illnesses  may  be  a  cause.  The 
nervous  system  is  a  potent  factor,  and  may  suppress  the 
menstruation  or  cause  amenorrhea  by  autosuggestion. 
Change  of  climate  and  prolonged  lactation  are  accountable 
for  numerous  cases. 

Symptoms. — These  arise  at  or  after  the  time  of  puberty, 
and  the  chief  symptom  is  absence  of  the  periodic  flow.  In 
amenorrhea  associated  with  atresia  no  external  signs  of 
bleeding  occur,  but  there  are  periodical  monthly  attacks  of 
colicky,  cramp-like  pains  in  the  pelvis,  increasing  in  severity 
as  the  retained  menstrual  blood  distends  the  uterus  or  vagina. 

Diagnosis. — When  the  symptoms  point  to  atresia  as  the 
cause,  a  careful  examination  under  anesthesia  should  be 
made.  Where  obstruction  exists,  an  imperforate  hymen, 
vagina,  or  cervix  will  usually  be  found.  The  pelvis  is  occu- 
pied by  a  soft  fluctuating  elastic  tumor  often  rising  above  the 
brim  of  the  pelvis.  If  no  atresia  exists,  and  the  pelvic  organs 
are  well  developed,  some  constitutional  cause,  such  as  anemia, 
chlorosis,  or  phthisis  must  be  sought. 

Treatment. — Where  atresia  of  the  hymen,  vagina,  or  cervix 
exists  the  treatment  is  operative  (see  page  54). 

In  cases  due  to  anemia  or  chlorosis  Blaud's  pills  are  indi- 
cated, and  every  endeavor  should  be  made  to  improve  the 
patient's  general  physical  condition. 


MENORRHAGIA. 

Definition. — Excessive  bleeding  at  the  menstrual  periods. 
Intermenstrual  hemorrhage  is  known  as  metrorrhagia. 

Pathology. — Is  that  of  the  condition  which  produces  it. 

Etiology. — The  causes  are  either  constitutional  or  local,  the 

latter  being  the  more  important.     These  are  endometritis, 

metritis,  displacements  and  malignant  diseases  of  the  uterus, 

fibroids,  polypi,  and  diseases  of  the  ovaries.     Chronic  alco- 

8 


114  MENSTRUATION  AND  ITS  DISORDERS 

holism  is  frequently  a  cause.  The  possibility  of  pregnancy 
with  impending  abortion  should  be  borne  in  mind. 

Symptoms. — Sudden  or  gradual  increase  in  the  amount  of 
blood  lost  during  the  periods,  secondary  anemia,  weakness, 
and  debility. 

Diagnosis. — Dependent  on  the  history  and  symptoms  of  the 
case.  Important  to  distinguish  between  menorrhagia  and 
metrorrhagia,  as  the  latter  is  often  the  first  sign  of  cancer  of 
the  uterus. 

Treatment. — In  young  girls  and  unmarried  women  ergot  is 
valuable,  thirty  drops  of  the  fluidextract,  three  times  a  day,  or 
styptol,  gr.  f ,  every  three  hours.  In  married  women  prolonged 
hot  douches  (120°  F.)  may  be  given.  A  local  examination  in 
urgent  cases  should  always  be  made.  Severe  hemorrhage 
may  require  vaginal  packing  and  the  hypodermic  injection 
of  ergotin  (10  to  20  minims). 

DYSMENORRHEA. 

Definition. — Pain  before,  during,  or  directly  after  the  period 
of  menstruation,  and  directly  referable  to  the  menstrual 
function. 

Pathology. — That  of  the  condition  producing  it.  Various 
theories  have  been  advanced  in  explanation  of  the  pain,  and  of 
these,  the  obstruction  and  congestion  theories  are  most  fre- 
quently referred  to. 

Obstruction  Theory. — That  an  angle  of  flexion  in,  or  a  nar- 
rowing of,  the  cervical  canal  offers  an  obstacle  to  the  outflow 
of  the  products  of  menstruation.  This  retention  stimulates 
contractions  in  the  uterus  in  order  to  effect  expulsion,  and 
the  attempt  to  overcome  the  mechanical  resistance  causes  the 
pain. 

Congestion  Theory. — That  the  pain  arises  from  the  resistance 
which  the  muscular  tissue  of  the  uterus  offers  to  the  hyper- 
emia. This  undue  vascular  tension  causes  compression  of  the 
nerve  endings,  and  pain  is  the  result. 


D  YSMENORRHEA  1 1 5 

It  is  probable  that  in  all  cases  of  dysmenorrhea  some  pelvic 
abnormality  exists  and  that  the  pain  is  due  to  the  increased 
determination  of  blood  to  tissues  already  in  a  state  of  chronic 
inflammation  or  congestion. 

Etiology. — A  small,  undeveloped  condition  of  the  pelvic 
organs  (infantile  type)  is  often  found.  Subinvolution  and  mal- 
positions of  the  uterus,  endometritis,  and  diseased  adnexa  are 
frequent  causes.  A  membranous  type  of  dysmenorrhea  is 
recognized  where  the  endometrium  is  discharged  in  shreds, 
or  as  a  complete  cast  of  the  uterine  cavity. 

Symptoms. — The  menstruation  may  be  either  scanty, 
moderate,  or  profuse.  The  pain  varies,  being  in  the  form  of 
slight,  intermittent  attacks  of  colic  preceding  or  occurring 
on  the  first  day  or  two  of  the  flow,  or  severe,  continuous,  and 
agonizing  in  character,  producing  in  some  cases  marked 
maniacal  symptoms. 

Diagnosis. — An  accurate  diagnosis  should  be  made,  as  upon 
this  depends  successful  treatment.  A  careful  vaginal  exami- 
nation, and  in  virgins  rectal  examination,  should  be  made,  under 
anesthesia  if  necessary,  and  the  condition  of  the  uterus  and 
appendages  determined. 

Treatment. — Any  marked  pelvic  lesion  will  usually  neces- 
sitate operative  treatment.  Posterior  displacements  of  the 
uterus  should  be  corrected,  and  when  of  long  standing  the 
accompanying  endometritis  calls  for  curettage.  The  free 
use  of  salines  before  and  laxatives  during  the  periods  to 
diminish  the  pelvic  congestion  is  of  great  service,  and  rest  in 
bed  and  the  hot-water  bag  are  valuable  adjuncts.  For  the 
actual  pain,  pulsatilla  in  5  minim  doses  every  hour,  or  styptol 
in  J  grain  tablets  every  three  hours,  will  be  found  of  service. 
Avoid  opium  and  alcohol  in  every  foriyi.  In  cases  due  to 
defective  development  of  the  pelvic  organs  in  young  girls 
only  palliative  treatment  is  justifiable;  general  tonics 
sh(Mihl  be  given  and  plenty  of  healtliy  outdoor  exercise 
ordered. 


CHAPTER  XIV. 
THE  DYNAMICS  OF  THE  FEMALE  PELVIS. 

There  has  existed  in  the  past,  and  still  exists  at  present,  con- 
siderable difference  of  opinion  regarding  the  normal  position 
of  the  uterus  and  the  means  by  which  this  position  is  main- 
tained. 

The  uterus,  more  so  than  any  other  organ  in  the  body, 
rests  in  a  state  of  unstable  equilibrium,  and  undergoes  fre- 
quent changes  in  position  consequent  upon  a  shifting  centre 
of  gravity  and  physiological  changes  in  the  adjacent  viscera. 

Being  of  small  bulk,  in  weight  less  than  three  ounces,  and 
suspended  by  highly  elastic  structures  in  a  cavity  large  enough 
to  admit  of  considerable  latitude  of  movement,  it  can  be 
readily  understood  how  very  slight  a  cause  may  often  be 
sufficient  to  produce  a  permanent  displacement. 

To  understand  how  the  normal  balance  is  maintained,  it 
will  be  necessary  to  turn  for  a  moment  to  the  anatomy  of  these 
parts.  With  the  woman  standing  upon  her  feet  the  pelvis 
occupies  an  oblique  position  with  regard  to  the  trunk  of 
the  body,  and  is  placed  at  an  angle  of  60  to  65  degrees 
with  the  ground  upon  which  she  stands.  Within  the  pelvis 
lies  the  uterus,  parallel  or  nearly  so  to  the  horizon,  its  fun- 
dus directed  forward  and  resting  by  its  anterior  face  on  the 
posterior  aspect  of  the  bladder,  to  which  it  is  united  by  a 
reflection  of  peritoneum.  The  cervix  is  directed  backward 
toward  the  hollow  of  the  sacrum,  perpendicular  to  the  axis  of 
the  vagina,  and  nearly  so  to  that  of  the  pelvis.  This  relative 
position  between  uterus  and  pelvis  remains  pretty  constant, 
though  considerable  variation  within  physiological  limits  may 
occur.  For  example,  as  the  bladder  fills  with  urine  it  rises 
in  the  pelvis,  carrying  the  fundus  upward  and  backward 
and  the  cervix  forward  until  the  fundus  approximates  the 
promontory  of  the  sacrum  and  the  uterine  axis  is  nearly 
(116) 


THE  DYNAMICS  OF  THE  FEMALE  PELVIS  117 

parallel  to  that  of  the  pelvis;  then,  as  the  bladder  is  emptied 
the  uterus  sinks  again  to  its  former  position.  An  overdistended 
rectum  crowds  the  uterus  well  forward,  even  flexing  the  cervix 
upon  the  fundus,  and  at  times  raising  the  fundus  well  out  of 
the  pelvis.  As  the  body  is  bent  forward  the  uterus  changes 
somewhat  its  position  in  the  pelvis,  which  it  tends  to  leave, 
approaching  the  abdominal  cavity.  In  the  dorsal  posture 
the  uterus  sinks  somewhat  back  toward  the  hollow  of  the 
sacrum,  although  normally  this  occurs  only  to  a  slight  degree. 

Now,  the  means  by  which  this  support,  allowing  as  it  does 
of  such  extensive  change  in  position,  is  accomplished  are  the 
same  as  in  all  other  organs  of  the  body,  namely,  suspension 
by  ligaments,  for  Nature  makes  no  exceptions  to  her  rules  and 
takes  no  chances,  and  here  on  the  cradle  in  which  she  nurtures 
to  fruition  her  greatest  and  most  marvellous  achievement,  she 
has  been  particularly  lavish,  as  no  other  organ  in  the  body 
compared  in  size  has  so  many  and  so  strong  ligaments  as  the 
uterus. 

The  principal  suspensory  ligaments  of  the  uterus  are  the 
uterosacral,  two  in  number,  passing  from  their  origin  at  the 
third  and  fourth  bones  of  the  sacrum  downward  and  forward 
to  their  insertion  at  the  waist  of  the  uterus.  Composed 
largely  of  connective  tissue,  they  are  not  as  elastic  as  the  other 
ligaments,  and  with  the  uterovesical  ligaments  running  for- 
ward to  the  bladder  form  a  firm  sling  of  tissue  which  holds  the 
cervix  in  place.  So  long  as  they  remain  intact  the  cervix 
stays  high  up  in  the  hollow  of  the  sacrum,  and  retrodisplace- 
ment,  the  first  step  of  which  is  descent  of  the  cervix,  cannot 
occur.  The  uterovesical  ligaments  together  form  a  thick 
fibrous  band,  connecting  the  neck  of  the  uterus  to  the  pos- 
terior surface  of  the  bladder,  and  control  the  anteroposterior 
motions  of  the  uterus. 

The  broad  ligaments  are  reflections  of  the  peritoneum, 
passing  from  the  lateral  walls  of  the  pelvis  to  the  sides  of  the 
uterus.  Their  role  is  largely  a  passive  one  in  relation  to 
the  uterus;  their  chief  function  seems  to  be  the  support  of  the 
uterine  appendages  and  bloodvessels  going  to  the  uterus. 


118      THE  DYNAMICS  OF  THE  FEMALE  PELVIS 

The  part  played  by  the  round  hgaments  is  largely  an 
accessory  one,  and  only  at  times  are  they  called  upon  to 
actively  enter  into  the  support  of  the  uterus.  Attached  to  the 
fundus,  they  serve  to  guide  and  limit  its  excursions  upv^^ard, 
and,  pulling  aWays  forward  by  virtue  of  their  attachment  at 
the  external  ring,  it  is  easily  seen  how  a  tendency  to  retro- 
version is  prevented  so  long  as  they  maintain  their  normal 
tone.  Largely  muscular  in  structure,  they  possess,  in  common 
with  other  muscles,  the  power  of  undergoing  hypertrophy, 
which  is  well  illustrated  in  pregnancy.  Here  they  enlarge 
with  the  uterus,  their  chief  function  being  to  hold  the  fundus 
well  forward  as  it  rises  in  the  abdominal  cavity,  thus  keeping 
it  in  contact  with  the  anterior  abdominal  wall  and  preventing 
injury  to  the  intestines  that  might  occur  should  they  become 
anterior  to  the  uterus  and  compressed  between  it  and  the 
abdominal  wall. 

After  delivery  involution  takes  place  in  the  ligaments  as 
well  as  in  the  uterus,  and  the  subsiding  fundus  is  held  forward 
until  it  again  reaches  the  pelvis  in  safety. 

The  malpositions  most  commonly  met  with  are  the  retro- 
deviations and  procidentia.  The  former  admit  of  two  divi- 
sions, the  versions  and  flexions,  the  difference  between  them 
being  simply  one  of  degree.  We  have  seen  how  normally  the 
uterus  lies  in  the  pelvis,  supported  by  the  broad  ligaments  on 
either  side,  and  the  firm  sling  of  tissue  composed  of  the  utero- 
sacral  and  uterovesical  ligaments  holding  the  cervix  well  up 
in  the  hollow  of  the  sacrum,  the  fundus  being  held  forward, 
guided  and  limited  in  its  excursions  by  the  round  ligaments. 
In  this  position  the  intra-abdominal  pressure  directed  against 
its  posterior  surface  helps  also  to  keep  the  fundus  forward. 
The  first  step  in  all  retrodisplacements  and  procidentia  is 
the  sinking  of  the  cervix,  which  results  when  the  support  of 
the  uterosacral  ligaments  is  lost.  This  brings  the  axis  of  the 
uterus  more  in  line  with  the  axis  of  the  pelvis,  changing  its 
horizontal  position,  and  admitting  of  a  posterior  recession 
of  the  fundus  to  the  limits  of  control  exerted  by  the  round 
ligaments.    This  position  is  an  extremely  hazardous  one  for 


THE  DYNAMICS  OF  THE  FEMALE  PELVIS 


119 


the  uterus  and  one  that  cannot  be  maintained  for  any  great 
length  of  time.  Sooner  or  later  the  round  ligaments,  unable 
to  stand  the  continuous  strain  put  upon  them,  yield,  either 
slowly,  or  suddenly,  as  in  the  traumatic  displacements,  thereby 


Normal  position  of  the  uterus.  The  uterus  Ues  anteposed,  anteverted,  and 
slightly  anteflexed  when  the  bladder  and  rectum  are  empty  and  the  patient  is  in 
the  upright  position.     (Findley.) 

allowing  the  fundus  to  recede  and  the  intra-abdominal  press- 
ure to  act  on  its  anterior  face,  forcing  it  back  into  the  hollow 
of  the  sacrum.  So  long,  then,  as  the  cervix  remains  in  place 
it  is  impossible   for   the  retrodeviations  and  procidentia  to 


120  DISPLACEMENTS  OF  THE  UTERUS 

develop,  for  the  fundus  and  cervix  cannot  change  their  positions 
to  any  extent  independently  of  each  other.  How,  then,  is  this 
relaxation  of  the  uterosacral  ligaments,  whereby  the  support 
of  the  cervix  is  lost,  brought  about  ?  Probably  the  all-impor- 
tant mechanical  factor  in  its  causation  is  the  constant  traction 
downward  exerted  on  the  cervix  by  the  posterior  vaginal  wall 
when  a  rectocele  exists,  for  in  complete  laceration  of  the 
perineum,  unaccompanied  as  it  is  by  the  formation  of  a  recto- 
cele, the  cervix  remains  in  place.  Bearing  these  facts  in  mind 
helps  greatly  to  an  understanding  of  the  process  by  which 
procidentia  is  brought  about.  Relaxation  of  all  the  uterine 
ligaments  permits  the  sinking  of  the  cervix,  the  swinging  back- 
ward of  the  fundus,  and  the  descent  of  the  uterus  in  the  pelvis, 
when  the  downward  pull  of  the  rectocele  and  cystocele,  plus 
the  intra-abdominal  pressure  from  above,  accomplish  the  rest. 

This  almost  continuous  tugging  of  the  rectocele  at  the  cervix 
is  probably  the  all-important  factor  in  causing  its  downfall, 
and  explains  the  reason  why  many  uncompleted  retrodis- 
placements  are  permanently  cured  by  replacing  the  uterus  and 
operative  correction  of  the  rectocele,  that  invariably  recurred 
under  other  forms  of  treatment. 

That  in  individual  cases  the  previously  normal  uterus  can 
lie  in  a  retroposed  position  without  in  any  way  affecting  the 
general  balance  of  health,  is  a  well-known  fact,  but  as  the  con- 
dition is  a  progressive  one,  proceeding  from  bad  to  worse, 
sooner  or  later  indications  for  its  correction  arise. 


CHAPTER  XV. 

DISPLACEMENTS  OF  THE  UTERUS. 

Uterine  displacement,  for  our  purpose,  may  be  classified 
into  the  minor  displacements,  consisting  of  retroversion,  retro- 


RETRODISPLACEMENTS  121 

flexion,  and  the  lateral  deviations;  and  the  major  displace- 
ments, procidentia,  inversion,  and  hernia. 

As  the  difference  between  retroversion  and  retroflexion  is 
largely  one  of  degree,  they  will  be  considered  together  under 
the  head  of  retrodisplacements. 

Anteflexion,  though  for  many  years  so  considered,  is  not 
properly  a  displacement,  but  rather  a  lack  of  development, 
and  is  considered  elsewhere. 


RETRODISPLACEMENTS. 

Definition." — Retroversion  of  the  uterus  may  be  said  to 
exist  when  the  axis  of  the  uterine  body  forms  an  obtuse 
angle  with  the  axis  of  the  pelvic  inlet,  and  retroflexion  when 
the  posterior  uterine  wall  is  bent  upon  itself. 

Pathology. — The  cervix  is  directed  downward  and  forward, 
lying  in  the  axis  of  the  vagina,  and  the  fundus  lies  posterior  to 
the  plane  of  the  pelvic  inlet.  There  is  passive  congestion 
with  its  accompanying  dilatation  of  the  bloodvessels  and 
increase  in  connective  tissue.  The  tubes  and  usually  the 
ovaries  follow  the  displaced  fundus.  Relaxation  and  loss  of 
tone  in  the  I'gaments,  the  supporting  structure  of  the  uterus, 
exist. 

Etiology. — A  certain  percentage  of  the  cases  are  congenital 
and  a  few  of  traumatic  origin.  Retroflexion  is  more  common 
than  retroversion,  and  is  more  often  found  in  multiparse, 
where  the  ligaments  and  pelvic  floor  are  relaxed  and  have  not 
regained  their  normal  tone.  Subinvolution  of  the  uterus  and 
its  ligaments  after  confinement  is  the  most  important  etio- 
logical factor.  Adhesions  resulting  from  diseased  appen- 
dages may  draw  the  uterus  into  a  position  of  retroversion. 

Symptoms. — Backache,  a  sense  of  weight  in  the  pelvis, 
constipation,  dysmenorrhea,  menorrhagia,  leucorrhea,  and 
sterility  or  repeated  abortion.  In  cases  of  long  standing 
general  constitutional  symptoms  develop. 


122 


DISPLACEMENTS  OF  THE  UTERUS 


Diagnosis. — On  vaginal  examination  the  cervix  is  found 
lying  in  the  axis  of  the  vagina  and  usually  low  down  in  the 
pelvis  (Fig.  31). 


Fig.  31 


Retroposition  and  retroversion  of  the  uterus,  with  fixation.  Peritoneal  adhesions 
bind  the  posterior  surfaces  of  the  uterus  to  the  sacrum  and  rectvim,  holding  the 
uterus  firmly  in  retroversion  and  retroposition.     (Findley,) 

Bimanual  examination  shows  absence  of  the  fundus  ante- 
riorly, and  reveals  a  firm,  rounded  body  in  the  posterior  fornix, 
continuous  with  the  cervix.  In  retroflexion  a  groove,  more 
or  less  distinct  according  to  the  degree  of  flexion  present, 
is  felt  between  the  cervix  and  fundus,  and  little  difficulty  is 


RETRODISPLACEMENTS 


123 


experienced  in  locating  the  fundus  low  down  in  the  pelvis — at 
times  on  a  level  with  the  cervix.  Differential  diagnosis  between 
retroflexion,  a  fibroid  in  the  posterior  uterine  wall,  or  a  small 


Fig.  32 


Retroversioflexion  of  the  uterus,  with  adhesions.  The  body  is  adherent  in  the 
cul-de-sac.  The  long  axis  of  the  uterus  is  bent  backward  and  the  cervix  is  directed 
downward.      (Findley,) 


prolapsed  adherent  ovarian  tumor,  is  often  difficult,  but  can 
usually  be  made  by  careful  and  repeated  bimanual  exami- 
nations, eventually  locating  the  fundus  in  front.  If  necessary, 
the  uterine  sound  may  be  brought  into  acquisition,  and  is  a 


124 


DISPLACEMENTS  OF  THE   UTERUS 


valuable  diagnostic  aid,  showing  at  once,  by  the  direction  it 
takes,  whether  the  fundus  is  anterior  or  posterior.  It  should 
only  be  used  under  rigid  aseptic  precautions,  and  never  when 
doubt  as  to  pregnancy  exists.  Having  located  the  fundus,  the 
next  step  is  to  decide  as  to  the  mobility  of  the  uterus,  whether 
freely  movable  or  fixed  by  adhesions.  When  the  adhesions 
are  low  down  between  the  uterus  and  rectum,  they  may  often 
be  felt  in  the  posterior  fornix,  and  repeated  attempts  to  elevate 
the  uterus  in  the  pelvis  meet  with  failure.  In  cases  where  the 
adhesions  are  very  extensive  downward  traction  on  the  cervix 
encounters  immediate  resistance,  the  uterus  lying  absolutely 
fixed  in  its  pathological  position  (Fig.  32). 


Fig.  33 


Author's  forceps  for  correcting  posterior  displacements  of  the  uterus. 


Non-operative  treatment  consists  in  the  reposition  of  the 
uterus  and,  where  possible,  retention  by  a  pessary.  When 
adhesions  make  this  impossible  operative  correction  of  the 
displacements  is  indicated.  In  cases  complicated  by  inflam- 
matory conditions  of  the  appendages  these  should,  as  a  rule, 
receive  appropriate  treatment  before  any  effort  is  made  to 
correct  the  displacement  of  the  uterus;  otherwise  much  harm 
may  be  done. 

Reposition  (Vaginal Method). — With  the  patient  in  the  dorsal 
position  and  her  thighs  well  flexed  on  the  abdomen,  the 
vagina  is  retracted,  the  anterior  cervical  lip  firmly  grasped 
with  a  traction  forceps  (Fig.  34),  and  steady  downward 
traction  made  for  a  few  moments  to  gradually  overcome  the 


RETRODISPLACEMENTS 


125 


resistance  of  the  tissues  (Fig.  35).     The  index  finger  of  the 
disengaged  hand  is  then  passed  as  high  up  against  the  pos- 


FiG.  34 


Retroflexion  of  the  uterus.    First  step  in  replacement. 
Fig,  35 


Retnjflexiun  of  the  uterus.    Second  .step  in  re[)lacement. 

terior  wall  of  the  uterus  as  p()ssi})le,  in  either  the  vagina  or 
rectum,  and  with  this  point  as  a  fulcrum  the  cervix  is  pushed 


126 


DISPLACEMENTS  OF   THE  UTERUS 


back  into  the  hollow  of  the  sacrum,  when  the  fundus  will 
swing  forward  into  position.  Occasionally  it  may  be  neces- 
sary to  assist  the  fundus  forward  by  counterpressure  over  the 
abdomen  (Fig.  36)~ 


Fig.  36 


Retroflexion  of  the  uterus.    Third  step  in  replacement. 

Reposition  (Bimanual  Method). — With  the  patient  placed 
in  the  position  already  described,  the  index  finger  in  the 
vagina  or  rectum  elevates  the  fundus  until  it  can  be  grasped 
by  the  abdominal  hand  and  drawn  forward.  The  success  of 
this  method  depends  on  extreme  relaxation  of  the  abdominal 
wall,  secured  by  the  intelligent  cooperation  of  the  patient  or 
the  administration  of  an  anesthetic. 

Reposition  (Gravity  Method). — In  many  simple  cases,  if  the 
patient  is  put  in  the  knee-chest  position,  gravity  will  correct 
the  displacement,  but  the  pessary  must  be  inserted  before 


RETRODISPLACEMENTS 


127 


the  patient  changes  her  position,  otherwise  the  fundus  will 
return  to  its  posterior  position.  In  difficult  cases  anesthesia 
may  be  required,  and  is  always  advisable  in  young  unmarried 
women. 

Fig.  37 


Albert  Smith  pessary  for  retroversion. 
Fig.  38 


Introduction  of  pessary. 

Introduction  of  the  Pessary. — In  selecting  a  pessary,  the  size 
and  shape  depend  much  on  the  recjuirements  of  each  indi- 
vidual case.  An  All^ert  Smith,  3-inch,  hard  rubber  retro- 
version pessary  (Fig.  37)  is  a  good  one  to  begin  with.    Having 


128 


DISPLACEMENTS  OF  THE   UTERUS 


replaced  the  uterus,  the  perineum  is  retracted  by  the  index 
finger,  and  as  the  vulvar  orifice  is  anteroposterior  and  the 
cavity  of  the  vagina  transverse,  the  pessary  must  be  intro- 
duced with  its  plane  surface  vertical  and  afterward  rotated 
into  the  same  plane  with  the  vagina  (Figs.  38,  39,  40),  the 
concavity  of  its  large  curve  being  in  contact  wth  the  anterior 
vaginal  wall.  The  index  finger  pushing  against  the  upper 
bar  guides  it  into  position  behind  the  cervix.    The  pessary  is 


Fig.  39 


Introduction  of  pessary. 

held  in  position  by  the  posterior  action  of  the  sacral  segment 
of  the  pelvic  floor  and  the  anterior  action  of  the  posterior 
face  of  the  pubic  segment,  between  which  it  is  compressed. 

The  function  of  the  pessary  is  to  hold  the  cervix  up  in  posi- 
tion, thus  relieving  the  tension  on  the  overstretched  utero- 
sacral  and  round  ligaments,  giving  them  a  chance  to  regain 
their  normal  tone  and  supporting  power. 

Operative  treatment  is  called  for  when  the  pessary  fails  to 
cure  and  where  adhesions  or  complicating   diseases  of  the 


RETRODISPLACEMENTS  129 

adnexa  exist.  It  may  be  either  extraperitoneal  or  intra- 
peritoneal. 

Extraperitoneal  Methods  (where  adhesions  or  diseased 
appendages  are  absent) : 

(a)  Vaginal  Fixation:  The  fundus  is  brought  forward  and 
sutured  to  the  anterior  vaginal  wall. 

Fig.  40 


The  pessary  in  position, 

(b)  Alexander- Adams  Operation:  The  fundus  is  brought 
forward  and  held  in  place  by  shortening  the  round  ligaments 
at  the  external  abdominal  rings. 

Intraperitoneal  Methods  (where  adhesions  or  diseased 
appendages  are  present) : 

(a)  Vaginal  Celiotomy:  Adhesions  are  separated,  any  dis- 
ease of  the  appendages  treated,  the  fundus  is  brought  forward 
9 


130 


DISPLACEMENTS  OF  THE   UTERUS 


and   vaginal    fixation    performed,    or   the   round   ligaments 
shortened. 

(h)  Abdominal  Celiotomy:  Adhesions  are  separated,  any 
disease  of  the  appendages  treated,  the  fundus  brought  forward 
and  sutured  to  the  abdominal  wall,  or  the  round  ligaments, 
uterosacral  ligaments,  or  both,  may  be  shortened  to  hold  the 
uterus  in  position 

LATERAL  DEVIATIONS  OF  THE  UTERUS. 

Lateral  displacements  are  of  little  importance,  rarely  giving 
rise  to  distinctive  symptoms.     The  uterus  may  be  found  in 


Fig.  41 


Left  laterodisplacement  of  the  uterus.     The  left  broad  ligament  is  thickened  and 
contracted  and  has  drawn  the  uterus  to  the  left.    (Findley.) 

displacement  to  the  right  or  left,  lying  only  slightly  to  one  side  of 
the  median  line,  or  well  over  to  the  pelvic  wall.    The  cause  of 


DOWNWARD  DISPLACEMENT  OF  THE   UTERUS      131 

the  displacement  will  usually  be  found  to  lie  in  the  appen- 
dages, or  broad  ligaments.  A  large  tumor  of  the  tube  or 
ovary  may  crowd  the  uterus  to  the  opposite  side  of  the  pelvis, 
or  it  may  be  drawn  to  one  side  by  contraction  in  the  broad 
ligament,  the  result  of  previous  inflammation  of  the  appen- 
dages on  that  side. 

Fig.  42 


Left  lateroversion  of  the  uterus.  The  uterus  is  crowded  to  the  left  side  of  the  pel- 
vis, the  long  axis  of  the  uterus  inclines  to  the  left.  The  cause  of  the  displacement  is 
a  broad  ligament  cyst  of  the  right  side  adherent  to  the  wall  of  the  pelvis.     (Findley.) 

The  treatment  is  that  of  the  pathological  condition  pro- 
ducing the  displacement. 


DOWNWARD  DISPLACEMENT  OF  THE  UTERUS. 

Definition. — A  descent  of  the  uterus  below  its  normal  level 
in  the  pelvis. 


132 


DISPLACEMENTS  OF  THE  UTERUS 


Varieties. — When  the  uterus  remains  in  the  vagina  the  con- 
dition is  called  incomplete  prolapse,  or  descensus  uteri,  and 
when  the  organ  escapes  at  the  vulva,  complete  prolapse,  or 
procidentia  (Figs.  43,  44). 


Primary  prolapse  of  the  uterus.     The  uterus  lies  wholly  outside  the  vulva.     The 
vaginal  walls  are  completely  inverted;  the  cervix  is  not  elongated. 

Pathology. — Descent  of  the  uterus  is  essentially  a  hernia 
through  the  pelvic  floor.  The  first  step  in  the  descent  of  the 
uterus  is  retroversion,  the  fundus  swings  back  into  the  hollow 
of  the  sacrum,  and  the  cervix  forward  into  the  axis  of  the 


DOWNWARD  DISPLACEMENT  OF  THE  UTERUS      133 

vagina.  The  second  step  is  the  sinking  of  the  uterus  in  the 
pelvis  until  the  cervix  appears  at  the  vaginal  outlet,  and  the 
final  step  is  the  complete  protrusion  (procidentia)  of  the  entire 

Fig.  44 


Secondary  prolapsus  uteri  with  elongation  of  the  cervix.  Both  vaginal  walls  are 
completely  inverted.  The  cervix  protrudes  from  the  vulva.  Neither  the  bladder 
nor  the  rectum  are  found  in  the  protruding  structures, 

organ  at  the  vulval  orifice,  with  inversion  of  the  vagina.  The 
appendages  usually  accompany  the  uterus,  and  are  often  found 
lying  in  the  vaginal  sac. 

The  anterior  vaginal  wall,  distended  by  the  bladder,  may 


134  DISPLACEMENTS  OF  THE   UTERUS 

come  down  first,  to  be  followed  later  by  the  posterior  vaginal 
wall,  drawing  with  it  the  rectum,  or  the  reverse  may  be  the  case. 

The  epithelium  of  the  vagina  and  vaginal  portion  of  the 
cervix,  exposed  to  the  air,  becomes  dry,  thickened,  and  hard, 
and  friction  of  the  clothing  may  produce  ulceration.  More 
or  less  elongation  of  the  supravaginal  portion  of  the  cervix 
generally  exists  in  all  but  the  acute  traumatic  cases. 

The  essential  cause  of  prolapse  is  a  weakening  of  the  supports 
of  the  uterus,  accompanied  by  a  yielding  of  the  pelvic  floor. 
This  is  favored  by  multiparity,  with  its  attendant  overstretch- 
ing or  injury  of  the  levator  ani  and  the  pelvic  fasciae.  The 
ever-present  downward  traction  exerted  by  the  cystocele  and 
rectocele  on  the  cervix  is  probably  the  most  important  mechan- 
ical factor.  Occasionally  the  fundus  remains  in  place,  when 
the  cervix  alone  descends  by  elongation  of  its  supravaginal 
portion.  In  prolapse  occurring  shortly  after  delivery,  gravity 
acting  on  the  large  subinvoluted  uterus  is  an  etiological 
factor.  Sudden  traumatic  prolapse  may  follow  extreme 
muscular  effort  or  a  fall  from  a  height,  and  has  been  observed 
in  nulliparous  women.  / 

The  symptoms  of  prolapsus  uteri  depend  on  the  extent  of  the 
displacement.  Slight  prolapse  may  produce  no  symptom 
other  than  a  dull  ache  in  the  lumbosacral  region,  aggravated 
by  exercise.  As  further  descent  occurs,  circulation  is  inter- 
fered with,  and  endometritis  and  menorrhagia  develop.  The 
prolapse  of  the  bladder  gives  rise  to  difficulty  in  micturition, 
cystitis,  and  vesical  irritability,  while  accompanying  the  pro- 
lapse of  the  rectum  there  are  difficult  defecation,  chronic 
constipation,  and  hemorrhoids. 

In  cases  of  sudden  prolapse,  shock  is  present,  with  the 
sensation  of  something  having  given  way  in  the  pelvis,  and 
marked  edema  of  the  uterus  and  vagina  appears. 

Diagnosis  of  Incomplete  Prolapse. — The  vaginal  finger 
encounters  the  cervix  low  down  in  the  axis  of  the  vagina;  the 
fundus  is  found  retroverted,  lying  in  the  hollow  of  the  sacrurri. 
When  the  patient  bears  down  the  uterus  descends  toward  the 
vaginal  outlet. 


DOWNWARD  DISPLACEMENT  OF  THE  UTERUS      135 

Diagnosis  of  Complete  Prolapse. — The  cervix  and  inverted 
vagina  are  seen  protruding  at  the  vulva,  and  on  palpation  the 
fundus  and  appendages  may  be  felt  lying  within  this  sac 
entirely  outside  of  the  introitus  as  shown  in  Fig.  45.  Hyper- 
elongation  of  the  cervix  simulates  prolapse,  but  the  thinned- 
out  portion  of  the  cervix  running  up  through  the  sac  can 
usually  be  made  out,  and  bimanual  examination  shows  the 
fundus  in  place. 

Fig.  45 


Procidentia. 


Treatment  of  Incomplete  Descent. — The  uterus  should  be 
replaced  and  a  retroversion  pessary  worn  for  six  months. 
Extreme  relaxation  of  the  vaginal  outlet  with  marked  cysto- 
cele  and  rectocele  should  be  corrected  by  operative  measures. 

Treatment  of  Procidentia. — The  uterus  should  be  replaced 
and  a  cup  or  ball  pessary  introduced  (Fig.  46).  This  accom- 
panied by  rest  in  bed,  with  daily  prolonged  hot  vaginal 
douches,  for  a  few  weeks  will  accomplish  marked  benefit,  even 
in  advanced  cases,  and  is,  as  a  rule,  all  that  is  indicated  in  very 


136  DISPLACEMENTS  OF  THE  UTERUS 

old  and  feeble  patients.  In  younger  women,  as  very  little  per- 
manent benefit  is  to  be  hoped  for  from  such  measures,  opera- 
tion is  indicated.  This  consists  in  amputation  of  the  cervix 
when  much  elongated,  repair  of  the  cystocele,  rectocele,  and 

Fig.  46 


Pessaries  for  procidentia. 

perineum,  with  shortening  of  the  round,  uterosacral  and  broad 
ligaments,  and  in  some  cases,  ventral  suspension  as  well.  In 
cases  that  are  not  cured  by  these  measures  vaginal  hysterec- 
tomy will  offer  the  best  chances  of  a  permanent  cure. 

INVERSION  OF  THE  UTERUS. 

Definition. — A  rare  condition,  where  the  uterus  is  turned 
inside  out.    May  be  either  acute  or  chronic. 

Pathology. — The  condition  has  its  onset  as  a  cup-shaped 
depression  of  the  uterine  wall,  usually  at  the  fundus,  and  as 
the  inversion  becomes  more  and  more  complete  the  fundus 
passes  through  the  cavity  of  the  uterus,  past  the  cervix,  into 
the  vagina,  and  out  at  the  vulva.  The  appendages  follow  the 
fundus.  In  acute  cases  the  inverted  organ  forms  a  large 
pear-shaped  tumor,  soft  and  vascular.  In  chronic  cases  the 
mass  is  smaller,  hard,  and  resembles  a  polypus.  Pathological 
changes  occur  in  the  exposed  endometrium,  and  friction  ulcers 
are  common.  The  inversion  usually  stops  at  the  cervix,  which 
forms  a  broad,  strong  ring  surrounding  the  neck  of  the  tumor. 
A  certain  amount  of  prolapse  accompanies  most  of  these  cases. 


INVERSION  OF  THE  UTERUS  137 

Etiology. — The  acute  form  may  arise  in  the  puerperium  as 
the  result  of  traction  on  the  cord  of  an  adherent  placenta,  and 
was  formerly  of  more  frequent  occurrence  before  the  proper 
management  of  the  third  stage  of  labor  was  well  understood. 
The  chronic  form  is  found  secondary  to  uterine  tumors, 
occurring  frequently  in  sarcoma,  and  as  a  rare  complication 
of  pedunculated,  submucous  fibroids. 

Symptoms. — In  the  acute  cases  there  are  severe  pain, 
hemorrhage,  and  even  collapse,  with  subsequent  swelling  and 
edema.  In  the  chronic  cases  there  is  constant  pain,  with  a 
sensation  of  weight  in  the  pelvis.  Severe  menstrual  and  inter- 
menstrual hemorrhages  occur,  and  the  patient  becomes  weak 
and  anemic.  A  profuse,  and  at  times  offensive,  leucorrhea  is 
usually  present. 

Diagnosis. — In  acute  cases  abdominal  palpation  shows  the 
rounded  fundus  replaced  by  a  cup-like  depression,  and  on 
vaginal  examination  a  large,  soft  body  is  found  to  fill  the 
vagina,  presenting  at  its  outlet.  If  the  placenta  has  not  been 
removed,  its  soft  friable  consistency  is  easily  recognized,  and 
care  should  be  taken  in  removing  it  not  to  further  increase 
the  inversion  (Fig.  47). 

In  chronic  inversion  the  diagnosis  is  more  difficult,  and  care 
is  required  to  distinguish  from  intra-uterine  polypus,  pedun- 
culated fibroid,  and  prolapse.  The  vaginal  finger  encounters 
a  rounded  vascular  tumor  that  bleeds  easily,  and  is  free  on  all 
sides,  as  the  finger  sweeps  around  it,  except  at  its  upper 
extremity,  which  is  encircled  by  the  dilated  cervix.  The 
sound,  passed  up  along  the  side  of  the  tumor,  enters  the  cer- 
vical canal  for  a  short  distance  only,  and  no  uterine  cavity  is 
found  beyond.  Bimanual  examination  shows  a  truncated 
body  with  a  cup-like  depression  in  place  of  the  fundus. 

Treatment. — In  acute  cases  immediate  manual  reposition 
should  be  practised,  and  offers  little  difficulty  if  the  case  is 
seen  early;  if  much  swelling  and  edema  are  present  prolonged 
hot  douches  should  he  first  given.  In  chronic  cases  reposition 
offers  many  difficulties,  operation  being  generally  required. 


188 


DISPLACEMENTS  OF  THE  UTERUS 


This  consists  of  anterior  vaginal  section,  with  incision  of  the 
cervix  up  to  a  point  on  the  anterior  uterine  wail  that  will  give 
space  enough  to  push  the  fundus  through  into  its  proper 
place;  the  incision  is  then  closed  with  catgut  sutures.  In 
cases  of  long  standing  this  may  prove  impossible  and  vaginal 
hysterectomy  be  required. 


Fig.  47 


Complete  inversion  of  the  uterus.     (Findley.) 

Hernia  of  the  Uterus. — A  rare  condition,  where  the  uterus 
is  found  in  the  sac  of  a  crural  or  inguinal  hernia,  or  an  enlarged 
pregnant  uterus  may  escape  forward  into  the  sac  of  a  ventral 
hernia. 


THE  MENOPAUSE  139 


ANTEFLEXION. 

Definition. — A  persistence  of  the  fetal  type  of  uterus, 
where  the  angle  of  flexion  between  the  cervix  and  fundus 
persists. 

Pathology. — Anteflexion  is  found  most  commonly  in  nul- 
liparae. The  angle  of  flexion  is  at  the  upper  portion  of  the 
cervix,  the  fundus  lying  well  forward  under  the  symphysis 
pubis,  and  the  cervix  is  bent  sharply  forward,  lying  in  the  axis 
of  the  vagina.  The  cervix  is  small  and  long,  and  usually  has 
a  small  external  os.    The  internal  os  is  often  constricted. 

Etiology. — A  congenital  condition.  An  acquired  form  is 
recognized  by  some  writers. 

Symptoms. — Dysmenorrhea  and  sterility  are  the  most 
prominent.  Leucorrhea  is  a  late  symptom,  and  dyspareunia 
— pain  on  sexual  intercourse — may  be  present. 

Diagnosis. — On  vaginal  examination  the  cervix  is  found  long 
and  conical,  and  lying  in  the  axis  of  the  vagina.  There  is  often 
a  tender  spot  behind  the  cervix.  The  examining  finger  in  the 
anterior  fornix  feels  the  angle  of  flexion  between  the  cervix 
and  the  fundus.  Bimanual  examination  confirms  the  anterior 
position  of  the  fundus,  which  is  usually  small  in  proportion 
to  the  size  of  the  cervix. 

Treatment. — When  anteflexion  is  associated  with  an  infan- 
tile uterus,  the  most  successful  treatment  is  that  directed 
toward  further  developing  the  uterus.  (See  Infantile  Uterus.) 
Various  intra-uterine  stem  pessaries  and  plastic  operations  on 
the  cervix  have  been  devised  for  the  treatment  of  anteflexion. 
Pregnancy  to  full  term  usually  effects  a  symptomatic  as  well 
as  an  anatomical  cure,  although  the  flexion  sometimes  persists 
after  delivery. 

THE  MENOPAUSE. 

Definition. — The  end  of  menstrual  life.  Also  called  the 
climacteric,  and  change  of  life. 


140  DISPLACEMENTS  OF  THE   UTERUS 

Pathology. — The  active  period  of  menstrual  life  lasts,  on  an 
average,  for  thirty  years,  and  lapses  into  abeyance  at  between 
the  fortieth  and  fiftieth  years.  With  the  establishment  of  the 
menopause  fertility  ceases — fifty-three  years  being  the  age 
limit  recognized  by  the  courts.  The  onset  may  be  sudden  or 
gradual.  Atrophic  changes  occur  in  the  pelvic  organs:  the 
uterus  shrinks,  its  muscular  tissue  partly  disappears,  and  its 
walls  become  thin,  soft,  and  relaxed.  The  ovaries  become 
small  and  cirrhotic,  and  the  Graafian  follicles  disappear.  The 
vagina  is  shortened  and  narrowed  and  loses  its  elasticity. 
Various  morbid  conditions  are  very  apt  to  develop  at  this 
time.  Premature  cessation  of  menstruation  may  occur  as  the 
result  of  mental  shock,  wasting  diseases,  or  change  of  climate. 
Artificial  menopause  follows  radical  operations  on  the  pelvic 
organs  when  the  ovaries  have  been  removed.  Too  radical  a 
curettage  may  have  the  same  effect. 

Symptoms. — Many  cases  are  unaccompanied  by  any 
unpleasant  symptoms,  though  nervous  disturbances,  such  as 
cardiac  palpitation,  sensations  of  heat  and  cold,  with  marked 
flushings  of  the  face,  are  the  rule.  Depression  of  spirits, 
melancholia,  and  even  mania  at  times  develop.  Irregular 
hemorrhages,  when  a  symptom,  should  always  be  carefully 
investigated  with  reference  to  possible  cancer. 

Diagnosis. — Usually  offers  little  difiiculty,  except  when  the 
menopause  occurs  prematurely.  Careful  observation  with 
the  history  of  the  case  should  settle  the  question. 

Treatment .^ — Exercise  and  fresh  air,  with  freedom  from 
anxiety,  worry,  and  alcohol,  are  essential.  The  nervous 
symptoms  should  receive  appropriate  treatment  as  they 
arise.  In  cases  of  artificial  menopause  thyroid  extract,  20  to 
30  grains  a  day,  is  of  service. 

Premature  menopause  may  be  at  times  averted  by  dilating 
the  cervix  and  firmly  packing  the  uterine  cavity  with  gauze. 
This  stimulates  contractions  in  the  uterine  muscle,  which  has 
a  tendency  to  check  the  beginning  atrophy. 


LACERATIONS  OF  THE  PERINEUM  141 

RELAXATION  OF  THE  VAGINAL  OUTLET. 

Definition. — A  loose,  gaping  introitus. 

Pathology. — The  supporting  structure  of  the  vaginal  outlet, 
the  anterior  portion  of  the  levator  ani  muscle,  has  sustained  a 
break  in  its  continuity,  or  has  been  stretched  to  a  point  where 
its  muscular  fibers  are  unable  to  contract  sufficiently  to  close 
the  introitus. 

Etiology. — Frequent  childbirth,  the  bearing  of  large  chil- 
dren, unduly  prolonged  perineal  stage  of  labor,  and  the 
performance  of  obstetrical  operations. 

Symptoms  are  those  arising  from  the  lack  of  proper  perineal 
support;  a  feeling  of  weight  and  pressure  in  the  pelvis. 

Diagnosis. — Upon  inspection,  with  the  patient  in  the  gyne- 
cological position,  the  vaginal  opening  is  seen  large  and  gap- 
ing. The  anterior  and  posterior  vaginal  walls  are  no  longer 
closely  approximated  but  lie  apart,  and  often  more  or  less 
everted,  constituting  cystocele  and  rectocele.  When  the 
patient  coughs,  or  bears  down,  a  marked  pouting  of  the  vagina 
results,  its  walls  tend  to  roll  out,  exposing  a  portion  of  the 
anterior  and  posterior  walls. 

The  examining  finger  in  the  vagina,  pressing  down  toward 
the  anus,  fails  to  encounter  the  firm  resistance  of  the  strong 
levator  ani  fibers. 

Treatment. — Slight  relaxation  requires  none.  When  the 
symptoms  are  progressive,  and  cystocele  or  rectocele  begins 
to  develop,  operative  repair  of  the  perineum  should  be  per- 
formed. 

LACERATIONS  OF  THE  PERINEUM. 

Definition. — A  tear  of  the  rectovaginal  septum.  IMay  be 
either  incomplete,  where  the  rectum  is  not  opened,  or  com- 
plete, where  the  rectal  and  vaginal  openings  are  converted 
into  one. 


142 


DISPLACEMENTS  OF  THE   UTERUS 


Pathology. — In  childbirth,  when  the  elasticity  of  the  peri- 
neal tissues  does  not  allow  of  sufficient  dilatation  for  the  birth 
of  the  presenting  part,  rupture  occurs  in  the  line  of  least 
resistance — usually  the  median  raphe,  though  laceration  to 
one  side  or  the  other  is  of  not  uncommon  occurrence.    The 


Fig.  48 


Muscles  of  the  female  perineum.     (Testut.) 

tear  may  be  only  through  the  fourchette  (first  degree),  down 
to  the  sphincter  ani  (second  degree),  through  the  sphincter  ani 
(third  degree),  or  into  the  rectum  (complete  laceration,  or 
fourth  degree). 

Etiology. — Important  predisposing  factors  are  rigidity  of 
the  soft  parts,  especially  in  elderly  primipara,  and  precipitate 


LACERATIONS  OF  THE  PERINEUM 


143 


labor.  A  large  head,  broad  shoulders,  persistent  occipito- 
posterior  positions,  and  the  various  obstetrical  operations  are 
also  common  causes. 

The  symptoms  are  usually  dependent  on  the  extent  of  the 
laceration  and  the  length  of  time  it  has  existed.  A  feeling  of 
weight  and  fulness  in  the  pelvis  are  generally  complained  of. 
Bladder  and  rectal  symptoms  are  present  if  the  laceration  has 


Fig.  49 


Fig.  50 


Complete  perineal  laceration. 
Before  operation. 


After  operation  (by  Ristine's 
method). 


been  extensive  enough  to  cause  the  development  of  a  cystocele 
and  rectocele.  In  complete  laceration  of  the  perineum  the 
patient  loses  control  of  gas  and  feces  in  the  rectum. 

Diagnosis. — Much  that  has  been  said  under  the  diagnosis 
of  relaxation  of  the  vaginal  outlet  applies  as  well  to  cases  of 
laceration.  The  normal  height  of  the  perineum  is  destroyed, 
the  vaginal  opening  approximates  the  anal,  until,  in  complete 


144  DISPLACEMENTS  OF  THE   UTERUS 

cases,  they  become  one.  The  vulval  opening  gaps  and  the 
anterior  and  posterior  vaginal  wall,  either  one  or  both,  are 
exposed  to  view  and  roll  outward  when  the  patient  strains. 
One  or  both  lateral  sulci  are  deeper  than  normal,  and  depres- 
sion with  the  examining  finger  fails  to  encounter  the  resistance 
of  the  trans  versus  perinei  fibers.  When  the  tear  has  gone 
through  the  sphincter,  the  normal  puckering  of  the  anus  will  be 
found  to  have  disappeared  anteriorly,  and  little  dimples  form 
on  either  side  denoting  the  retracted  ends  of  the  sphincter 
muscle.  The  anal  and  rectal  mucous  membrane  may  be 
exposed  and  the  examining  finger  introduced  into  the  rectum 
meets  with  little  or  no  resistance  at  the  anus. 

Treatment. — The  proper  prophylaxis  for  saving  the  peri- 
neum belongs  to  obstetrics.  Immediate  repair  should  always 
be  performed.  Secondary  repair  is  called  for  in  the  presence 
of  marked  symptoms. 


CYSTOCELE. 

Definition. — A  hernia  of  the  bladder  into  the  vagina. 

Pathology. — As  a  result  of  relaxation,  or  destruction,  of  its 
normal  supports  the  bladder  descends  into  the  pelvis,  push- 
ing before  it  the  anterior  vaginal  wall.  The  anterior  vaginal 
wall  yields,  its  fascia  thins  out  and  disappears,  or  becomes  so 
stretched  that  the  bladder  approaches  and  may  even  partially 
escape  at  the  vaginal  opening.  As  the  bladder  sinks  into  the 
pelvis,  increasing  difficulty  in  micturition  is  experienced,  the 
patient  is  no  longer  able  to  thoroughly  empty  her  bladder,  and 
the  residual  urine  eventually  causes  a  cystitis,  accompanied 
by  more  or  less  dilatation  of  the  bladder. 

Etiology. — Laceration  of  the  perineum  with  its  resulting 
relaxation  of  the  pelvic  floor  is  an  important  etiological  factor- 
Traumatic  cases  in  nulliparae  are  occasionally  seen.  A  pro- 
lapsing uterus  may  drag  the  bladder  with  it  in  its  descent, 
though  it  is  possible  in  some  cases,  that  the  cystocele  causes 


CYSTOCELE 


145 


the  prolapse.  Undue  relaxation  of  the  vesical  ligaments  and 
pelvic  floor,  with  habitual  overdistention  of  the  bladder,  are 
responsible  for  the  majority  of  cases  (Fig.  51). 


Fig.  51 


Laceration  of  the  perineum  showing  cystocele  and  rectocele. 


Symptoms. — A  sensation  of  weight  and  dragging  in  the 
pelvis,  accompanied,  when  the  bladder  is  full,  by  a  feeling  of 
distention  at  the  vaginal  outlet.  Vesical  irritability  and 
cystitis  are  later  symptoms. 

Diagnosis. — In  the  dorsal  position,  on  examination,  the 
anterior  vaginal  wall  is  seen  presenting  at  the  vulva,  forming 
in  marked  cases  a  distinct  tumor,  which  increases  in  size  on 
10 


146 


DISPLACEMENTS  OF  THE  UTERUS 


Fig.  52 


straining.  This  tumor  may  be  replaced,  and  its  size  increased 
or  decreased  by  filling  or  emptying  the  bladder.  Retraction 
of  the  posterior  vaginal  wall  shows  that  the  anterior  wall  no 
longer  forms  a  straight  line  from  the  introitus  to  the  cervix, 
but  bulges  down  into  the  vagina.  The  nor- 
mal folds,  or  rugse,  are  obliterated,  and  the 
surface  is  smooth,  pale  and  has  a  stretched 
appearance.  In  extreme  cases,  when  the 
bladder  comes  outside  the  introitus,  its 
vaginal  covering,  from  exposure  to  the  air 
and  friction  of  the  clothing,  is  dry  and 
hard. 

Treatment. — Palliative  treatment  by  pes- 
saries is  suitable  in  certain  cases.  If  the 
cystocele  is  slight,  and  the  relaxation  of  the 
vaginal  outlet  moderate,  good  results  may 
be  obtained  with  Skene's  pessary  (Fig.  52). 
In  more  extreme  cases  the  cup  pessary  may  be  tried.  Com- 
plete cure,  however,  is  only  accomplished  by  operative 
measures.  Anterior  vaginal  section  should  be  performed, 
the  bladder  freed  from  the  anterior  vaginal  wall  and  from 
the  uterus  up  to  the  peritoneal  reflection,  and  replaced.  The 
thinned-out  portion  of  the  vaginal  wall  is  removed  and  the 
incision  closed  by  suturing  the  vaginal  wall  to  the  uterus  from 
the  cervix  to  the  peritoneal  reflection.  Relaxation  of  the 
vaginal  outlet  should  be  corrected  at  the  same  time. 


Skene's  pessary. 


REGTOGELE. 

Definition. — A  hernia  of  the  anterior  rectal  wall  into  the 
vagina. 

Patholo^. — Relaxation  or  laceration  of  the  levator  ani 
muscle  deprives  the  lower  end  of  the  rectum  of  its  proper 
support,  so  that  during  the  expulsion  of  feces,  forward  disten- 
tion of  the  anterior  wall  into  the  vagina  results.    The  posterior 


GENITAL  FISTULA  147 

vaginal  wall  is  carried  before  the  advancing  anterior  rectal  wall, 
and  appears  at  the  introitus  as  a  bulging  tumor,  increased  in 
size  with  every  expulsive  effort.  This  dragging  on  the  pos- 
terior vaginal  wall  causes  downward  traction  on  the  cervix, 
which  may  eventually  produce  hyperelongation  of  the  cervix, 
retroversion,  or  prolapse  of  the  uterus.  Feces  are  forced  into 
this  pouch  and  difficulty  in  emptying  the  rectum  is  often 
experienced. 

Etiology. — Difficult  labor  and  prolongation  of  the  perineal 
stage,  resulting  in  an  overstretching,  or  laceration,  of  the 
levator  ani  muscle,  are  the  exciting  causes. 

Symptoms. — The  chief  symptoms  are  difficulty  in  defeca- 
tion and  inability  to  entirely  empty  the  rectum.  There  is, 
in  addition,  a  feeling  of  weight  and  depression  in  the  pelvis. 

Diagnosis. — Easily  made  with  the  patient  in  the  dorsal 
position.  Through  the  gaping  introitus  the  posterior  vaginal 
wall  presents  as  a  soft,  rounded  tumor  increasing  in  size  on 
expulsive  effort,  and  disappearing  on  pressure.  The  index 
finger  introduced  into  the  rectum  readily  demonstrates  the 
distended  anterior  rectal  wall,  which  may  be  pushed  forward 
into  the  vagina  and  out  through  the  vaginal  orifice. 

Treatment. — Palliative  management  is  directed  toward  pre- 
venting the  rectocele  from  increasing  in  size  by  regulating 
the  bowels  and  thus  avoiding  the  injurious  effects  of  chronic 
constipation  with  its  violent  expulsive  efforts.  Radical  treat- 
ment consists  in  the  operative  repair  of  the  perineum  and 
pelvic  floor. 

GENITAL  FISTULA. 

Definition. — A  genital  fistula  is  an  abnormal  opening 
between  the  uterus  or  vagina  and  the  urinary  tract  or  intes- 
tines fFig.  53). 

Pathology. — The  fistulse  most  often  met  with  are  vesico- 
vaginal, where  the  communication  is  between  the  bladder  and 
vagina.    Of  less  frequent  occurrence  are  rectovaginal,  between 


148 


DISPLACEMENTS  OF  THE   UTERUS 


the  rectum  and  vagina;  urethrovaginal,  between  the  urethra 
and  vagina;  uretero vaginal,  between  the  ureter  and  vagina; 
vesico-uterine,  between  the  bladder  and  uterus.  Rare  forms 
sometimes  encountered  are  utero-uterine,  rectoperineal,  and 
enterovaginal. 


Fig.  53 


Location  of  various  forms  of  fistula:  1,  vesico-uterine  fistula;  2,  vesico-utero- 
vaginal  fistula;  3,  vesicovaginal  fistula;  4,  urethrovaginal  fistula;  5,  rectovaginal 
fistula;    6,  rectolabial  fistula;    7,  fistula  in  ano. 

Etiology. — Vesicovaginal,  rectovaginal,  urethrovaginal,  and 
vesico-uterine  fistulse  are  generally  seen  as  the  result  of  tissue 
necrosis  following  prolonged  pressure  of  the  fetal  head  in 
labor,  and  were  formerly  much  more  common  than  at  present, 
due  to  delay  in  the  use  of  forceps.  Any  of  the  fitsulse  may 
result  from  the  sloughing  of  malignant,  growths  or  from 
injury  inflicted  at  operation. 

Symptoms. — The  characteristic  symptom  is  the  involuntary 
discharge  of  urine  or  feces  through  the  abnormal  opening. 


STERILITY 


149 


Diagnosis.— The  greatest  difficulty  is  at  times  encountered 
in  locating  the  fistula.  If  large,  it  may  usually  be  seen  and 
probed  by  proper  retraction  of  the  tissues,  but  when  small  and 
high  up,  other  means  are  often  necessary.  For  the  vesical 
fistulse  the  bladder  should  be  emptied  by  catheter  and  injected 
with  a  colored  solution,  sterilized  milk,  or  methylene  blue,  so 
that  its  point  of  escape  may  be  more  easily  seen.  The  small 
fecal  fistulse  are  more  readily  located  by  blackening  the  stools 
with  bismuth  subnitrate  or  charcoal. 

Treatment. — Spontaneous  closure  sometimes  occurs  during 
the  first  year,  but  rarely  later.  In  all  chronic  cases  radical 
operative  measures  give  the  best  results. 

STERILITY. 

Definition. — Incapability  of  reproduction. 

Varieties. — The  reproductive  function  is  the  most  complex 
and  probably  least  understood  of  all  the  functions  of  life. 
Sterility,  in  the  usual  acceptance  of  the  term,  implies  that 
condition  in  which  the  woman  does  not  conceive,  or  if  con- 
ception occurs  she  is  unable  to  bear  a  viable  and  living  child. 
When  conception  has  never  occurred  the  term  applied  is 
absolute  sterility,  and  when  conception  takes  place,  but  early 
death  of  the  embryo  or  fetus  habitually  occurs,  resulting  in 
abortion  or  the  birth  of  a  non-viable  child,  the  condition  is 
said  to  be  one  of  relative  sterility. 

In  many  cases  of  absolute  sterility  the  fault  is  with  the  male, 
and  the  female  is  only  too  often  unjustly  blamed.  But  the 
question  of  male  sterility  does  not  concern  us  here,  save  to 
emphasize  the  fact  that  his  fertility  should  never  be  taken  for 
granted.  No  woman  should  be  accused  of  sterility  and  her 
life  endangered  by  a  serious  surgical  operation  aimed  at  its 
correction,  without  first  examining  her  husband's  spermatozoa 
and  deciding  his  fertilizing  powers. 

Etiology  .—The  causes  of  sterility  may  be  considered  imder 
age,  structural  defects,  either   congenital  or  acquired,   and 


150  DISPLACEMENTS  OF  THE   UTERUS 

functional.  The  age  of  the  woman  has  a  strong  bearing  on 
the  question.  Matthew  Duncan  investigating  this  subject  in 
England,  found  "that  about  7  per  cent,  of  all  the  marriages 
between  fifteen  and  nineteen  years  of  age,  inclusive,  were 
without  offspring;  that  those  married  at  ages  from  twenty  to 
twenty-four,  inclusive,  were  almost  all  fertile;  and  that  after 
that  age  sterility  gradually  increases  according  to  the  greater 
age  at  the  time  of  marriage."  Among  the  congenital  defects 
should  be  mentioned  imperforate  hymen;  absence  or  mal- 
formation of  the  vagina,  uterus,  ovaries,  or  tubes.  Of  the 
acquired  structural  defects,  many  are  the  result  of  a  previous 
inflammation  which  has  occluded  the  tubes  or  so  thickened 
the  cortex  of  the  ovaries  that  the  ova  cannot  escape.  Endo- 
metritis, whether  primary  or  secondary  to  displacements  of 
the  uterus,  affords  an  unfavorable  soil  for  the  lodgement  and 
growth  of  the  fecundated  ovum.  Cervical  lacerations  and 
svphilis  are  responsible  for  many  cases  of  habitual  abortion. 
The  functional  causes  are  complex.  Good  health,  plenty  of 
outdoor  exercise,  and  the  avoidance  of  alcohol  are  favorable 
to  fecundity,  while  luxury  and  great  wealth  with  their  atten- 
dant evils  appear  to  go  hand-in-hand  with  sterility. 

Treatment. — The  average  interval  between  marriage  and 
the  birth  of  the  first  child  is  twenty  months.  If  after  several 
years  of  married  life  conception  has  not  occurred,  or  a 
viable  child  not  been  born,  the  cause  should  be  sought  for. 
Congenital  and  acquired  defects  should  receive  their  appro- 
priate treatment. 

When  no  bar  to  conception  has  been  found,  but  where  the 
sterility  is  of  long  standing  and  conditions  warrant  it,  explora- 
tory celiotomy  may  be  performed,  and  many  times  the 
fimbriated  ends  of  the  tubes  will  be  found  closed  by  thin 
cobweb-like  adhesions,  the  cause  of  the  sterility.  When 
these  are  separated  and  the  tube  opened,  conception  fre- 
quently occurs  within  the  first  six  months  after  operation. 


CHAPTER  XVI. 

GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE. 

The  classes  of  surgical  operations  on  women  required  for 
the  treatment  of  diseases  pecuhar  to  them  are  two,  minor  and 
major. 

Fig.  54 


Doyen's  traction  forceps. 


Fig.  55 


Pryor's  dilator  (small). 

The  minor  operations  comprise  dilatations  of  the  cervix, 
curettage,  repair  of  the  cervix,  repair  of  the  perineum,  the 
various  minor  surgical  operations  on  the  vulva  and  vagina,  and 
the  extraperitoneal  operations  for  the  correction  of  retrodis- 
placements  of  the  uterus. 

The  major  operations  include  all  procedures  where  the 
peritoneal  cavity  is  opened.  Two  methods  of  approach  are 
available,  the  abdominal  and  the  vaginal.  Occasionally  both 
may  be  used  with  advantage  in  the  same  case. 

(151) 


152     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 


Fig.  56 


Wathen's  dilator  (large). 
Fig.  57 


Abbey  needle-holder. 


Fig.  58 


Foerster's  sponge-holder. 


GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE     153 


Fie.  60 


Jl^^  —    ■•^V--i?f'=c^J'^i^'^T-  =^1-'  -^H^  a  -  h~  'J-'JJ 


Martin's  uterine  sound. 


Q9td= 


Fig.  61 


Sims'  tampon  screw. 


3^illIIII» 


Fig.  62 


Scalpel. 
Fig.  63 


Author's  modification  of  Doyen's  abdominal  retractor. 


154     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 


Fig.  64 


Fig.  65 


Fig.  66 


Eastman's  retractor.  Tissue  forceps.  Garrigues'  speculum. 

Fig.  67  Fig.  68  Fig.  69 


Pean's  3  inch  artery  clamps. 


«(1 


Pean's  8  inch  artery  clamp. 


GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE     155 

Fig.  70  Fig.  71  Fig.  72 


Pcan's  hysterectomy  clamp. 


Scissors. 


Fig.  73 


Fritsch-Bozeman  uterine  irrigator. 


156     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

Fig.  74  Fig.  75  Fig.  76 


Deschamps'  ligature  carrier.     Pryor's  trowel  retractor.      Author's  trowel  retractor. 


THE  MINOR  OPERATIONS. 

Preparation  and  Position  of  the  Patient. — The  patient  is 
placed  in  the  dorsal  position  with  the  buttocks  well  over  the 
edge  of  the  table.  The  knees  are  flexed  on  the  thighs,  the 
thighs  flexed  on  the  abdomen,  and  retained  in  place  by  leg- 
holders.  The  vulva  should  be  shaved,  scrubbed  with  gauze 
wet  with  tincture  of  green  soap,  and  washed  with  sterile  water. 


THE  MINOR  OPERATIONS 


157 


Fig.  77 


Fig.  78 


ACTUAL  SIZE 


Author's  angiotribe. 


Author's  intestinal  forceps  with  rubber  jaws. 


The  vagina  should  be  thoroughly  cleansed  with  the  tincture  of 
green  soap,  preferably  with  the  patient  in  the  knee-chest 
position,  and  a  final  prolonged  douche  of  sterile  water  given. 
Preparation  of  the  Surgeon's  Hands. — Scrub  for  five  minutes 
the  hands  and  forearms  with  the  tincture  of  green  soap,  wash 
in  sterile  water,  scrub  for  two  minutes  in  Stewart's  solution: 


Sulphate  of  aluminum 3J 

Chloride  of  lime SiJ 

Water Oij 

And  give  a  final  rinsing  in  sterile  water. 


]58     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

Fig.  79 


Doyen's  tumor  screw. 

Dilatation  of  the  Cervix. — The  instruments  required  are, 
a  retracting  vaginal  speculum,  preferably  of  the  self-retaining 
type,  a  pair  of  strong  traction  forceps  for  holding  the  cervix, 
and  a  small  and  large  pair  of  cervical  dilators. 

With  the  patient  in  the  dorsal  position,  the  posterior  vaginal 
wall  well  retracted,  the  anterior  cervical  lip  is  firmly  grasped 
with  the  heavy  traction  forceps  and  drawn  down  as  near  the 
vaginal  outlet  as  possible.  The  dilator  is  then  introduced 
into  the  cervical  canal  up  to  its  shoulder,  the  traction  on  the 
cervix  relieved,  and  before  dilatation  is  begun,  the  cervix, 
with  the  dilator  in  place,  is  pushed  up  into  the  vagina  until  the 
vaginal  walls  are  put  well  on  the  stretch.  By  this  procedure, 
recommended  by  Goffe,  the  cervix  is  firmly  held  on  the  dilator 
during  dilatation,  and  there  is  no  danger  of  its  jumping  off 
and  the  blades  of  the  dilator  accidentally  tearing  the  cervix. 
If  the  cervix  is  held  down  in  view  during  dilatation,  it  is  pos- 
sible for  the  traction  forceps  to  tear  out,  releasing  the  cervix, 


THE  MIXOR  OPERATIONS  I59 

which,  as  it  slides  of!  the  dilator,  may  be  badly  lacerated  by 
the  points  of  the  dilator  blades.  This  accident  unfortunately 
is  of  only  too  common  occurrence. 

Having  observed  this  precaution,  dilatation  is  now  begun 
by  gradually  separating  the  blades  of  the  dilator,  and  con- 
tinued until  the  desired  degree  of  dilatation  ls  reached.  The 
pressure  of  the  dilator  should  be  constant  rather  than  inter- 
mittent, and  gradually  increased,  so  as  to  dilate  and  not  tear 
the  muscular  fibers  in  the  cervix.  The  time  required  depends 
on  the  rigidity  of  the  cervical  tissues,  but  should  not,  as  a 
rule,  be  less  than  ten  minutes,  as  this  is  about  the  length  of 
time  required  to  thoroughly  dilate,  and  so  paralyze  the  mus- 
cular fibers  that  immediate  contraction  of  the  cervix  will  not 
occur. 

Curettage. — Instruments  Required. — In  addition  to  those 
necessary  for  dilatation  of  the  cerv'ix,  a  uterine  sound,  two 
curettes  (small  and  medium),  a  sponge  holder,  a  uterine 
irrigator,  and  a  tampon  screw  are  necessarv. 

Following  the  preliminary  dilatation  of  the  cervix,  the 
operator  should  make  a  thorough  exploration  of  the  uterine 
cavity  with  the  sound  to  determine  its  size  and  any  irre2;ulari- 
ties  in  shape. 

1.  If  the  patient  presents  a  case  of  retained  secundines,  thev 
should  be  removed  as  thoroughly  as  possible  with  the  sponge 
holder  or  placental  forceps  and  the  rough  surface  of  the 
uterine  wall  denoting  the  placental  site  lightly,  but  thoroughly, 
gone  over  with  the  curette. 

2.  ^^^ren  the  operation  is  performed  for  a  case  of  chronic 
endometritis,  the  curette  is  carried  up  to  the  fundus,  firm 
pressure  made  against  the  uterine  wall,  and  a  strip  of  endo- 
metrium removed  by  a  steady  downward  stroke  of  the  curette 
as  far  as  the  internal  os.  At  the  end  of  the  stroke,  all  press- 
ure on  the  curette  is  stopped  and  the  instrument  again  gentlv 
carried  up  to  the  fundus,  repeating  the  process  until  the  whole 
interior  of  the  uterus  has  been  covered,  removing  all  the  dis- 
eased endometrium.   Strong  and  steady  downward  traction  on 


160     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

the  cervix  during  the  operation  straightens  out  the  uterine 
canal,  so  that  in  anteflexion  and  retroflexion  the  surface  at  the 
fundus  is  more  easily  reached  with  the  curette.  The  cervix 
during  a  curettage  should  never  be  held  by  an  assistant,  but 
always  by  the  operator  himself.  Following  the  curettage  the 
uterus  should  be  irrigated  for  three  minutes  with  a  normal 
saline  solution  at  a  temperature  of  110°  F.  If  packing  of  the 
uterus  is  indicated,  a  tape  of  sterile  bichloride  or  iodoform 
gauze  is  carried  up  to  the  fundus  with  the  tampon  screw,  and 
the  whole  uterine  cavity  firmly  packed  down  to  the  internal 
OS.  The  end  of  the  uterine  gauze  in  the  vagina  is  tied  to  a 
wide  strip  of  gauze,  with  which  the  vagina  is  packed,  and  a 
vulvar  pad  worn  to  absorb  the  drainage.  On  the  third  day 
all  the  gauze  is  removed  and  a  hot  vaginal  saline  douche  given 
three  times  a  day  for  a  week. 

In  curetting,  my  preference  is  for  the  sharp  curette,  which 
surely  removes  the  endometrium  more  thoroughly  and  with 
less  traumatism  than  does  the  dull  instrument,  and  if  due 
care  be  used  is  just  as  safe. 

Imperforate  Hymen. — Technique. — A  small  incision  is 
made  through  the  hymen,  and  any  retained  blood  or  mucus 
in  the  vagina  slowly  evacuated.  The  incision  is  then  enlarged 
to  the  full  width  of  the  hymen  and  crossed  at  right  angles  by 
another  of  the  same  length.  A  thorough  vaginal  douche  is 
given  and  the  vagina  lightly  packed  with  gauze.  The  hymen 
is  frequently  quite  thick,  though  rarely  very  vascular,  so  that 
the  gauze  packing  generally  controls  any  undue  bleeding. 
The  gauze  is  removed  on  the  third  day  and  another  douche 
given.  The  patient  should  be  subsequently  examined  at 
monthly  intervals,  and  the  opening  kept  patent  with  dilators 
if  necessary  until  all  chance  of  closure  from  cicatricial  con- 
traction is  past. 

Trachelorrhaphy.  —  Preliminary  dilatation  and  curettage 
usually  precede  the  operation,  and  the  additional  instruments 
required  are  two  retractors  for  the  vagina,  six  artery  clamps, 
a  pair  of  scissors,  a  heavy  pair  of  tissue  forceps,  two  traction 


THE  MINOR  OPERATIONS 


161 


Fig.  80 


Trachelorrhaphy,  both  sides  denuded.     (Davenport.) 
Fig.  81 


Trachelorrhaphy,  sutures  in  position  on  both  sides.     (Davenport.) 
11 


162     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

forceps,  a  knife,  a  needle-holder,  two  full  curve  \\  inch 
Hagedorn  needles,  and  for  suture  material,  either  No.  3  silk- 
worm gut  or  chromicized  catgut. 

The  vaginal  walls  are  retracted,  exposing  the  cervix  to  view, 
the  anterior  and  posterior  cervical  lips  grasped  with  the  small 
traction  forceps  and  drawn  firmly  down  and  to  one  side. 
In  cases  of  unilateral  tear  it  is  usually  only  necessary  to  repair 
the  one  side,  whereas  in  the  bilateral  and  stellate  types  both 
sides  should  be  operated  upon.  Passing  the  knife  into  the 
cervical  canal,  slight  incisions  are  made  on  the  anterior  and 
posterior  walls  from  the  internal  to  the  external  os,  so  out- 
lining the  internal  limits  of  denudation  as  to  leave  a  strip  of 
mucous  membrane  \  inch  wide  on  both  lips  to  line  the  new 
cervical  canal.  With  the  point  of  the  knife,  the  cervix  is  then 
transfixed. on  its  vaginal  aspect  at  the  angle  of  the  tear,  and 
the  external  limits  of  denudation  outlined  on  both  lips  (Figs. 
80  and  81).  Care  should  be  taken  to  include  all  diseased  tissue 
within  these  limits.  The  outlined  areas  are  then  removed 
with  either  the  knife  or  scissors,  cutting  well  down  to  healthy 
tissue.  The  sutures,  usually  three  to  four  on  each  side,  are 
introduced  through  one  lip  at  a  time,  and  should  be  entered 
on  the  vaginal  aspect  J  inch  from  the  raw  edge,  pass  well 
under  the  denuded  area,  and  emerge  at  the  edge  of  the  central 
strip  of  mucous  membrane.  The  needle  is  then  entered  at  a 
corresponding  point  on  the  opposite  lip,  passed  in  a  similar 
manner,  and  brought  out  on  the  vaginal  aspect  at  a  point 
opposite  its  first  point  of  entrance.  The  sutures  should  not  be 
tied  until  all  are  passed.  The  cervical  lips  are  now  separated, 
all  blood  clots  removed,  and  the  stitches  tied,  just  tight  enough 
to  snugly  approximate  the  tissues  without  undue  tension.  If 
silkworm  gut  has  been  used,  the  ends  should  be  left  2  inches 
long,  or  all  tied  together  to  facilitate  their  subsequent  removal. 
A  daily  vaginal  douche  is  given  and  the  stitches  removed  at 
any  time  after  fourteen  days. 

Amputation  of  the  Cervix. — The  instruments  required  are 
the  same  as  for  trachelorrhaphy. 


THE  MINOR  OPERATIONS  163 

Technique. — With  a  small  traction  forceps  on  either  lip  the 
cervix  is  drawn  strongly  down  and  held  firmly  in  position.    A 

Fig.  82 


Amputation  of  the  cervix.      Cervix  drawn  down  and  circular  incision  made, 
separating  the  vagina  at  its  point  of  contact. 

circular  incision  with  the  knife  separates  the  vagina  from  the 
cervix  at  its  point  of  attachment,  and  })y  blunt  dissection  the 
cervix  is  freed  from  the  surrounding  tissues.     During  this 


164     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

dissection  pressure  should  always  be  directed  against  the 
cervix  to  avoid  injury  to  the  bladder  in  front  or  the  rectum 


Fig.  83 


.>>^ 


Amputation  of  the  cervix,  bilateral  division  of  the  cervix. 

behind.  At  either  side,  where  the  vessels  enter  the  cervix,  the 
tissues  should  be  ligated  with  catgut  close  to  the  cervix  and 
cut.     When  the  desired  length  of  cervix  has  been   bared, 


THE  MINOR  OPERATIONS 


165 


amputation  by  transverse  incision  is  performed.  The  anterior 
and  posterior  vaginal  flaps  are  now  sewed  to  the  cervical 
stump  in  such  a  manner  as  to  cover  its  raw  surface,  leaving 


Fig.  84 


Amputation  of  the  cervix,  sutures  in  position. 


the  cervical  canal  patent,  and  approximating  vaginal  and 
cervical  mucosa  at  the  new  external  os.  Deep  sutures  of 
silkworm  gut,  or  chromic  gut,  should  be  used  for  attaching 


166     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

the  vagina  to  the  cervix,  and  plain  catgut  for  accurate  super- 
ficial approximation.  The  stitches  should  not  be  removed 
before  the  end  of  the  second  week. 

Cystocele. — The    instruments  required    and  the  patient's 
position  are  the  same  as  for  trachelorrhaphy. 


Fig.  85 


Operation  for  cystocele,  showing   separation  of  bladder  from   cervix  and   anterior 
vaginal  wall.     (Wertheim  and  Micholitsch.) 

Technique. — The  cervix,  grasped  with  a  pair  of  traction 
forceps,  is  drawn  strongly  down  to  the  vaginal  outlet  and 
lateral  retractors  introduced.  A  longitudinal  incision  is  made 
through  the  anterior  vaginal  wall  from  the  cervix  to  the 
anterior  limit  of  the  cystocele,  usually  about  one  inch  from 


THE  MINOR  OPERATIONS  167 

the  opening  of  the  urethra.  The  bladder  is  now  dissected 
free  from  the  vagina,  well  into  the  lateral  fornices,  and  from 
the  uterus  up  to  the  peritoneal  reflection.  A  self-retaining 
catheter  is  introduced  into  the  bladder  and  the  urine  with- 
drawn. Curved  incisions  in  the  vagina  on  either  side  of  the 
longitudinal  one  extending  well  out  into  normal  the  vaginal 
tissue,  and  uniting  above  and  below,  remove  the  thinned-out 
portion  of  the  anterior  vaginal  wall.  Interrupted  sutures  of 
silkworm  gut  approximate  the  raw  edges  of  the  vagina. 
These  begin  at  the  cervical  end  of  the  wound,  and  each  includes 
a  portion  of  the  anterior  uterine  wall  up  to  the  peritoneal 
reflection.  Beyond  this  point  they  pass  through  the  vaginal 
flaps  only.  The  self-retaining  catheter  is  kept  open  for  forty- 
eight  hours  to  prevent  distention  of  the  bladder,  and  is  then 
removed.  The  sutures  are  removed  at  the  end  of  the  third 
week. 

In  cases  of  very  large  cystocele,  Goffe's  operation  may  be 
performed  as  follows:  When  the  peritoneal  reflection  of  the 
bladder  on  the  uterus  is  reached,  "the  vesico-uterine  pouch  is 
entered  and  the  peritoneum  torn  across  the  face  of  the  uterus 
and  well  out  on  to  the  face  of  the  broad  ligaments.  The  blad- 
der is  stitched  by  an  interrupted  suture  of  chromic  gut  at 
three  points  only,  the  middle  of  the  anterior  face  of  the  uterus 
and  two  points  on  the  broad  ligaments  sufficiently  wide  apart 
to  spread  out  the  bladder  wall.  The  sutures  are  all  passed 
and  left  sufficiently  long  to  protrude  from  the  vulva  before 
any  one  is  tied.  When  all  three  are  in  place  the  middle  one  is 
tied  first,  then  the  others." 

Perineorrhaphy.  —  The  choice  of  operative  procedure 
depends  on  the  degree  of  relaxation  of  the  vaginal  outlet 
present,  and  the  extent  of  the  vaginal  tear.  For  simple  cases 
almost  any  of  the  methods  devised  will  give  good  results. 
Where  extreme  relaxation  exists  the  operations  of  Emmet 
and  Goffe  are  particularly  applicable.  For  secondary 
repair  of  complete  perineal  laceration,  Ristine's  operation  is 
ideal. 


168     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

The  instruments  required  are  the  same  as  for  trachelor- 
rhaphy. 

Emmet's  Perineorrhaphy. — The  accompanying  illustrations 
are  so  graphic  that  but  little  explanatory  text  is  required. 
In  making  the  denudation,  as  Kelly  says:  "No  one  pattern 
will  fit  all  cases;  as  an  excessive  relaxation  requires  a  more 

Fig.  86 


Emmet's  perineorrhaphy. 


extensive  resection  than  one  of  moderate  degree.  The  cor- 
rect pattern  to  have  in  mind  in  resecting  is  the  nulliparous 
outlet."  The  limits  of  the  area  of  denudation  being  decided 
upon,  the  tissue  to  be  removed  should  first  be  outlined  with 
the  knife.  The  incisions  in  the  vaginal  sulci  should  be  one 
to  two  inches  long,  depending  on  the  amount  of  relaxation 


THE  MINOR  OPERATIONS 


169 


present.  The  flap  of  tissue  removed  should  include  the 
whole  thickness  of  the  vaginal  wall.  Hemorrhage  is  often 
profuse,  but  is  easily  controlled.  For  the  deep  sutures  silk- 
worm gut  is  the  preferable  material. 


Pig.  87 


Emmet's  perineorrhaphy. 


Goffe's  Perineorrhaphy. — The  lines  of  incision  extend  from 
the  highest  point  on  the  rectocele,  outward,  to  the  lowest 
caruncle  on  either  side,  and  are  connected  by  following  the 
curve  of  the  mucocutaneous  juncture  below.  This  tri- 
angular flap  of  tissue,  composed  of  the  vaginal  mucous  mem- 
brane, is  stripped  off  in  one  piece  from  the  underlying  tissue 
by  blunt  dissection.     The  method  of  passing  the  sutures  is 


170     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

very  well  shown  in  the  illustration  (Fig.  88).  "Catching  the 
tissue  at  the  upper  part  of  the  rectocele  with  an  artery  clamp, 
which  is  elevated  by  the  hand  of  an  assistant  and  with  the 
index  finger  of  the  left  hand  in  the  rectum,  the  needle  is 

Fig.  88 


Perineorrhaphy.     Goffe's  method  of  denuding  and  inserting  sutures. 


inserted  about  one-quarter  inch  from  the  angle  of  the  denu- 
dation. Passing  through  the  mucous  membrane,  the  needle 
is  swept  out  toward  the  side  of  the  pelvis  and  gradually 
curved  toward  the  median  line  until  it  emerges  near  it,  and 
about  one  inch  and  one-half  down  the  rectocele.     It  is  then 


THE  MINOR  OPERATIONS  171 

withdrawn,  and  again  inserted  about  one-eighth  inch  on  the 
opposite  side  of  the  median  hne,  and  swept  back  through 
the  tissues  in  a  reverse  direction  until  it  emerges  upon  the 
mucous  membrane  at  a  point  equally  distant  from  the  angle 
of  denudation  and  corresponding  with  the  point  of  insertion. 
A  second  stitch  is  inserted  about  one-quarter  inch  farther 
down  the  edge  of  the  mucous  membrane,  and  made  to  pursue 
a  course  corresponding  to  the  first  suture.  ''In  inserting, 
these  sutures  should  be  passed  sufficiently  far  down  the 
rectocele  to  carry  it  entirely  up  into  the  vagina  when  the 
sutures  are  tightened.  The  two  or  three  succeeding  sutures 
which  are  similarly  passed  bring  together  the  separated  edges 
of  the  muscle  and  fascia  in  front  of  the  rectocele.  The  last 
suture  is  inserted  just  above  the  position  of  the  caruncle, 
which  was  removed  on  one  side,  swept  down  around  the 
entire  circumference  of  the  denuded  surface,  and  made  to 
emerge  above  the  site  of  the  corresponding  caruncle  on  the 
opposite  side.  It  will  be  noticed  that  the  sutures,  instead  of 
being  passed  through  the  skin,  as  in  Emmet's  operation,  are 
inserted  in  the  mucous  membrane  of  the  vagina,  and  take 
their  points'of  support  from  the  fascia,  thus  lifting  the  recto- 
cele and  anus,  instead  of  dragging  them  down,  as  is  true  of  the 
operation  mentioned." 

Ristine's  Perineorrhaphy. — "The  basic  principle  of  this 
operation  is  inserting  into  the  rectum  a  frill  of  mucous  and 
cicatricial  tissue  which  is  dissected  from  the  vagina.  The 
advantages  of  the  operation  over  all  others  is  obvious.  The 
rectum  is  shut  off  completely  from  the  denuded  area  by  the 
inverted  frill,  with  its  mucous  surface  forming  the  anterior 
wall  of  this  organ,  giving  an  unbroken  rectal  mucous  lining. 
There  are  no  stitches  in  the  rectum  to  carry  infection  or 
require  removal." 

The  technique  as  described  by  Ristine  is  as  follows:  ''Out- 
lining with  the  eye  the  extent  of  the  lateral  denudation 
requisite  to  construct  a  perfect  perineum,  and  noting  the 
extent  of  the  rectal  rent,  I  Ipegin  high  up  in  the  vagina,  and 


172     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

dissect  off  an  apron  or  frill  of  mucous  and  cicatricial  tissue, 
corresponding  to  the  extent  of  the  vaginal  tear,  and  propor- 
tioned to  the  length  of  the  rectal  laceration,  down  to  the  apex 
of  this  rent,  making  sure  to  have  enough  of  tissue  when 
released  from  above  to  fold  over  the  rectal  rent  and  extend 
somewhat  beyond  the  sphincter  ani  when  that  shall  have  been 
closed.  Extending  my  dissection  laterally  to  the  points  I  have 
selected  for  the  lower  border  of  the  future  vagina  and  upper 
of  the  perineum,  I  continue  down  the  torn  edge  of  the  peri- 
neum (at  the  juncture  of  the  mucous  membrane  and  skin)  to 
a  point  well  below  the  pits  representing  the  retracted  ends  of 
the  sphincter  ani  muscle.  Just  here  is  where  failure  overtakes 
many  operators;  not  only  should  the  integumentocicatricial 
tissue  surrounding  this  pit  be  freshened,  but  most  essential, 
stretch  the  sphincter  ani  muscle,  draw  out  the  retracted  ends 
with  tenacula,  and  scarify  them  thoroughly.  Dissect  the 
lateral  flaps  down  as  close  to  the  rectal  tear  as  it  can  be 
carried  without  interfering  with  its  integrity  at  this  point. 
During  all  the  dissection  avoid  buttonholing  the  apron  or 
frill.  Now,  having  freed  the  apron  from  all  attachments, 
save  that  to  the  margin  of  the  rectal  rent — which  must  not 
be  disturbed — I  insert  the  apron  into  the  rectum,  thereby 
converting  the  smooth  vaginal  tissue  into  a  lining  for  the 
anterior  rectal  wall,  and  leaving  a  raw  perineovaginal  surface 
to  be  dealt  with  as  would  a  simple  Hegar  perineorrhaphy, 
except  the  union  or  adjusting  of  the  sphincter  muscle,  which 
is  accomplished  by  passing  a  chromicized  catgut  suture 
through  the  drawn-out  ends  of  the  muscle,  gentle  traction  is 
made  upon  this  suture,  causing  the  ends  of  the  muscle  to 
approximate;  now  pass  a  silkworm-gut  suture  through  skin 
and  muscle,  taking  a  more  secure  hold,  so  as  to  reinforce  and 
release  the  strain  on  a  catgut  anastomosis  suture,  and  place 
the  sphincter  ends  in  comfortable  apposition  when  this  suture 
is  tightened.  Observe,  now,  that  we  have  only  a  simple  incom- 
plete laceration  to  deal  with,  the  rectum  securely  shut  off,  and 
no  stitch  in  it  to  carry  infection  or  require  removal.     Place 


FISTULA  173 

the  vaginal  and  perineal  sutures  just  the  same  as  is  done  in 
any  simple  perineorrhaphy — vaginal,  of  chromicized  catgut, 
and  perineal,  of  silkworm  gut/' 

The  after  treatment  of  perineorrhaphy  is  simple.  The 
wound  area  should  be  kept  clean  and  protected.  The  patient 
may  be  allowed  to  void,  the  urine  being  diluted  as  passed  by  a 
saline  irrigation  played  over  the  surface  of  the  wound.  It  is 
desirable  that  the  first  few  stools  after  operation  be  semiliquid. 
This  may  be  accomplished  by  teaspoonful  doses  of  compound 
licorice  powder  given  at  frequent  intervals,  beginning  as  soon 
as  the  stomach  will  tolerate  it.  Daily  vaginal  douches  may  be 
given  if  indicated.  The  non-absorbable  sutures  should  be 
removed  on  the  fifteenth  day,  when  the  patient  may  with 
safety  leave  her  bed. 

Failure  to  secure  primary  union  in  secondary  repair  of  the 
perineum  is  of  rare  occurrence,  and  is  usually  due  to  the 
introduction  of  too  many  sutures.  Just  as  few  as  possible 
should  be  used,  and  tied  only  tight  enough  to  snugly  approxi- 
mate the  tissues,  avoiding  all  unnecessary  constriction,  that 
so  often  interferes  with  the  proper  nutrition  of  the  tissues. 


FISTUL-ffl. 

Definition. — The  genital  fistulse  are  abnormal  openings 
connecting  the  perineum,  vagina,  or  uterus  with  the  urinary 
tract  or  intestines. 

Operative  treatment  of  genital  fistulae  in  general  consists  of 
freeing  the  two  communicating  cavities  at  the  site  of  the 
fistula,  and  closing  the  opening  in  each  separately. 

Vesicovaginal. — Technique. — The  vaginal  wall  is  freely 
incised,  through  the  fistula,  down  to  the  bladder.  The 
bladder  is  then  separated  from  the  vagina  by  blunt  dissection 
for  one-half  inch  surrounding  the  fistula.  The  edges  of  the 
bladder  opening  are  then  freshened  and  united  by  interrupted 
sutures  of  chromic  catgut  passed  through  the  outer  coats  of 


174     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

the  bladder  down  to  but  not  including  the  mucous  lining. 
The  vaginal  incision  is  closed  by  interrupted  sutures  of  silk- 
worm gut  (Fig.  89).     The  bladder  sutures  are  introduced 

Fig.  89 


Repair  of  vesicovaginal  fistulse.     (Doderlein  and  Kronig.) 

close  together,  not  more  than  one-eighth  of  an  inch  apart. 
The  bladder  should  be  continuously  drained  by  means  of  a 
self-retaining  catheter  for  from  four  to  six  days  after  the 
operation,  and  the  week  following  its  removal  the  patient 


FISTULA  175 

should  be  required  to  void  her  urine  every  two  hours,  day  and 
night. 

Vesico-Uterine. — Through  an  anterior  vaginal  section 
the  bladder  is  freed  from  the  uterus  up  to  the  fistula.  The 
opening  in  the  bladder,  after  freshening  its  edges,  is  then 
closed  with  interrupted  chromic  gut  sutures  reinforced  with 
a  continuous  Lembert  suture  of  the  same  material.  The 
opening  in  the  uterus,  unless  large,  does  not  require  suturing, 
and  may  be  left  to  close  spontaneously.  The  incision  in  the 
anterior  vaginal  wall  is  closed  and  the  bladder  drained  as 
previously  described. 

Urethrovaginal. — The  opening  in  the  urethra  is  disclosed 
by  incising  the  vagina  over  the  fistula,  the  edges  of  the  urethral 
opening  are  freshened  and  brought  together  by  interrupted 
sutures  of  chromic  gut,  and  the  vaginal  incision  closed  in  the 
same  manner.    Subsequent  bladder  drainage  is  unnecessary. 

Ureterovaginal. — These  fistulse  are  usually  the  result  of 
injury  inflicted  during  vaginal  operations.  When  of  small 
size  they  will  often  close  spontaneously  if  the  ureter  is  cathe- 
terized  and  the  catheter  left  in  place  for  three  days.  The 
operative  repair  is  difficult,  and  usually  has  to  be  done  through 
an  abdominal  incision.  The  posterior  peritoneum  is  opened, 
disclosing  the  ureter,  as  close  to  the  fistula  as  possible.  A 
ureteral  catheter  should  be  introduced  before  the  operation  is 
begun  and  left  in  place  for  several  days  afterward.  The 
edges  of  the  fistula  are  freshened  and  sutured  together  with 
interrupted  sutures  of  fine  linen  thread.  When  this  cannot  be 
satisfactorily  accomplished,  the  ureter  should  be  divided,  the 
distal  end  ligated,  and  the  proximal  end  implanted  into  the 
bladder  at  such  a  point  as  to  leave  the  ureter  free  from 
tension. 

Rectovaginal. — An  incision  is  made  through  the  fistulous 
opening  in  the  vagina.  By  blunt  dissection  the  vagina  is 
separated  from  the  rectum  for  one-half  inch  in  all  directions, 
l^he  edges  of  the  openings  in  })oth  vagina  and  rectum  are  now 
freshened  and  separately  sutured.     When  possible  the  lines 


176     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

of  sutures  should  cross  each  other  at  right  angles.  A  rectal 
tube  is  kept  in  the  rectum  for  forty-eight  hours  after  operation, 
to  avoid  gas  distention.  In  some  cases  the  fistula  will  be  found 
too  high  up  in  the  vagina  to  repair  by  this  route,  when  the 
abdominal  must  be  selected,  the  operation  then  being  per- 
formed the  same  as  for  enterovaginal  fistula. 

Rectoperineal. — These  fistulse  must  first  be  treated  by 
incising  the  overlying  tissue  down  to  the  fistulous  tract.  This 
severs  the  sphincter  ani  muscle,  allowing  the  proper  denuda- 
tion of  the  sinus  tract.  The  wound  is  then  sutured  in  a 
manner  similar  to  that  employed  in  dealing  with  perineal 
lacerations  involving  the  sphincter  ani  muscle. 

Rectolabial. — By  free  incision  the  sinus  tract  is  laid  bare, 
converting  it  into  a  simple  fistula  in  ano. 

Enterovaginal. — Success  seldom  attends  the  operative 
repair  of  these  fistulse  when  performed  through  the  vagina, 
though  it  may  be  attempted  if  the  vagina  is  sufficiently  large 
to  allow  plenty  of  working  room.  As  a  rule,  the  abdomen 
must  be  opened,  the  intestine  freed  at  the  point  of  communi- 
cation with  the  vagina,  and  the  fistulous  opening  repaired 
separately.  This  is  easily  accomplished  now  that  the  liberated 
intestine  can  be  drawn  up  within  reach.  After  freshening  the 
edges,  the  opening  is  closed  by  a  purse-string  suture  of  fine 
linen  thread,  reinforced  with  a  Lembert  suture  of  the  same 
material.  The  vaginal  opening  can  be  left  to  close  spon- 
taneously or  drained  with  gauze. 

Anterior  Vaginal  Celiotomy. — The  special  instruments 
required  are  a  weighted  speculum,  two  retractors,  trowel 
retractors,  large  traction  forceps,  two  small  traction  forceps, 
small  and  large  artery  clamps,  curved  and  straight  long- 
handled  scissors,  sponge  holders,  ligature  carrier,  needle 
holder,  small,  medium,  and  large  needles,  ligature  material, 
two  scalpels,  and  heavy  tissue  forceps.  The  patient  is  placed 
in  the  dorsal  position,  the  speculum  introduced,  the  cervix 
grasped  with  the  large  traction  forceps,  and  strong  down- 
ward traction  made.    An  anterior  transverse  incision  (Fig.  90) 


ANTERIOR  VAGINAL  CELIOTOMY 


111 


one  inch  long  separates  the  vagina  from  its  attachment  to 
the  anterior  cervical  lip.  The  uterovesical  ligament  is 
picked  up  with  the  forceps  and  severed,  and  by  blunt  dis- 


Fig.  90 


Anterior  vaginal  celiotomy.     (Wertheim  and  Micholitsch.) 


section  the  bladder  is  freed  from  the  uterus  up  to  the  peri- 
toneal junction.  An  additional  longitudinal  incision  is  made 
through  the  anterior  vaginal  wall  to  within  one  inch  of  the 
urinary  meatus,  and  the  bladder  freed  from  the  anterior 

12 


178     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

vaginal  wall  on  both  sides.  Introducing  the  trowel  retractor 
between  the  bladder  and  uterus,  the  peritoneum  is  exposed 
and  incised  transversely  at  its  uterine  reflection,  thus  opening 
directly  into  the  peritoneal  cavity. 

The  trowel  then  elevates  the  bladder,  the  omentum  and 
intestines  are  packed  aw^ay  with  small  celiotomy  pads,  and 
adhesions  separated  with  the  index  finger  passed  over  the 
fundus.  The  following  operative  procedures  may  then  be 
carried  out. 

Anterior  Vaginal  Celiotomy  for  Retrodisplacements. — 
Vaginal  Fixation. — The  fundus  is  drawn  forward  into 
contact  with  the  anterior  vaginal  wall,  and  held  in  place 
by  a  silkworm-gut  suture.  This  passes  through  the  vaginal 
flaps  at  about  the  middle  point  of  the  longitudinal  incision, 
taking  a  bite  in  the  anterior  uterine  wall  at  a  point  high 
enough  up  on  the  fundus  to  hold  it  well  forward  in  position. 
It  is  tied  just  tight  enough  to  approximate  the  fundus 
and  the  vaginal  wall;  the  longitudinal  incision  is  closed 
with  interrupted  sutures,  the  transverse  left  open  for  drain- 
age. Where  there  are  no  adhesions,  or  complicating  disease 
of  the  appendages,  it  is  not  necessary  to  make  the  longi- 
tudinal incision  or  to  open  the  peritoneal  cavity.  The 
transverse  incision  suffices.  Through  it  the  bladder  is  separ- 
ated from  the  uterus  up  to  the  peritoneal  reflection,  and 
from  the  anterior  vaginal  wall  up  to  a  point  midway  between 
the  cervix  and  urinary  meatus.  The  fundus  is  brought 
forward  by  traction  at  the  peritoneal  reflection,  or  by  intro- 
ducing the  uterine  sound,  and  the  silkworm-gut  suture  passed. 
This  suture  can  be  removed  at  any  time  after  the  third  week. 

Short-ening  the  Round  Ligaments. — Each  ligament  is  grasped 
at  a  point  1  to  2  inches  from  the  uterus,  depending  on  the 
degree  of  relaxation  present,  and  drawn  forward  to  develop 
a  loop.  The  folds  of  the  loop  are  transfixed  and  brought 
together  by  interrupted  sutures  of  medium-sized  silk  or  linen 
thread;  the  free  end  of  the  loop  is  sutured  to  the  fundus  just 
in  front  of  the  tube  (Fig.  91), 


ANTERIOR  VAGINAL  CELIOTOMY 


179 


Shortening  the  Ovarian  Ligament. — The  ligament  is  grasped 
with  the  forceps  at  its  middle  point  and  looped.  One  or  two 
fine  silk  or  linen  thread  sutures  unite  the  folds. 


Fig.  91 


Shortening  the  round  ligaments  through  the  anterior  vaginal  incision  for  retrodis- 
placement.     (Wertheim  and  Micholitsch.) 


Salpingectomy. — The  tube  is  freed  from  adhesions,  delivered 
into  the  vagina,  ligated,  and  removed. 

Oophorectomy. — The  ovary  is  freed  from  adhesions,  deliv- 
ered into  the  vagina,  its  pedicle  ligated  and  cut,  and  the  organ 


180     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

removed.     Resection  of  the  tube  or  ovary  instead  of  removal 
may  be  practised  if  indicated. 

Posterior  Vaginal  Celiotomy. — Posterior  vaginal  celiot- 
omy has  a  limited  field  of  usefulness,  and  is  performed  prin- 


FiG.  92 


Posterior  vaginal  celiotomy.     (Wertheim  and  Micholitsch.) 


cipally  for  diagnostic  purposes  in  doubtful  cases  of  ectopic 
gestation,  and  for  pelvic  drainage. 

Technique. — The  posterior  cervical  lip  is  grasped  with  the 
heavy  traction  forceps  and  drawn  strongly  down  to  the 
vaginal  outlet.    A  transverse  incision  one  and  one-half  inches 


VAGINAL  HYSTERECTOMY  igi 

long  at  the  junction  of  the  posterior  vaginal  wall  with  the 
cervix  separates  the  two,  and  by  blunt  dissection  with  the 
index  finger  (Fig.  92),  exerting  pressure  against  the  uterus, 
the  rectum  is  freed  up  to  its  peritoneal  reflection.  The  peri- 
toneum is  then  caught  and  incised  transversely,  affording 
direct  entrance  to  the  peritoneal  cavity.  At  the  conclusion 
of  the  operation  the  peritoneum  may  be  closed  by  sutures  and 
the  vaginal  wound  left  open,  or  a  gauze  drain  left  in  place 
without  suturing. 

Vaginal  Hysterectomy.— Technique.— The  weighted  spec- 
ulum is  introduced,  both  lips  of  the  cervix  grasped  with  the 
heavy  traction  forceps,  and  strong  downward  traction  made 
to  steady  the  uterus.  A  circular  incision  around  the  cervix  at 
the  vaginal  junction  separates  the  vagina  from  the  cervix. 
The  peritoneum  is  opened  posteriorly,  care  being  taken  to  keep 
close  to  the  uterus  so  as  not  to  injure  the  rectum,  and  the  index 
finger  in  the  cul-de-sac  of  Douglas  frees  the  uterus  and  appen- 
dages from  any  posterior  adhesions.  The  anterior  fornix  is 
now  opened  the  same  as  in  vaginal  celiotomy.  Although  the 
longitudinal  incision  in  the  anterior  vaginal  wall  is  not  always 
necessary,  it  affords  more  working  room  and  is  generally 
advisable.  The  broad  ligaments  are  now  quilted  off  with  a 
long  continuous  ligature  passed  close  to  the  cervix  to  avoid 
including  the  ureters.  The  amount  of  tissue  included  in  each 
bite  of  the  ligature  should  not  exceed  one-half  of  an  inch,  and 
should  be  cut  each  time  before  another  knot  is  tied.  When  the 
uterine  artery  is  reached,  its  pulsation  may  be  readily  felt 
between  the  thumb  and  index  finger.  Beyond  this  point  the 
ligature  can  be  gradually  carried  far  enough  out  into  the 
broad  ligament  to  surround  the  appendages  without  danger 
to  the  ureter.  As  the  free  edge  of  the  broad  ligament  is 
reached  the  round  ligament  should  be  caught  up  and  tied 
with  a  separate  ligature.  The  continuous  ligature  then  sur- 
rounds the  free  border  of  the  broad  ligament,  between  the  in- 
fundibulopelvic  ligament  and  the  appendages,  is  finally  tied, 
and  the  included  tissue  cut.     For  the  broad  ligament  ligature. 


182     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

heavy  chromic  catgut,  kangaroo  tendon,  silk  or  linen  thread 
cut  in  one  foot  strands  is  generally  used,  and  may  be  passed 
on  either  a  large  full  curved  needle  or  a  ligature  carrier.  The 
knots  should  be  tied  as  tight  as  possible  without  breaking,  and 
the  tissue  cut  far  enough  away  to  avoid  all  danger  of  subse- 
quent slipping.  In  most  cases  the  quilting  of  the  broad  liga- 
ments should  be  done  part  way  on  one  side,  and  then  on  the 
other,  so  that  the  uterus  and  appendages  may  be  further 
delivered  into  the  vagina  with  each  succeeding  step.  If  the 
uterus  is  large  it  may  be  safely  hemisected,  after  both  uterine 
arteries  have  been  tied,  and  each  half  removed  separately,  or 
by  morcellation.  When  contraction  of  the  broad  ligaments 
makes  ligation  beyond  the  uterine  arteries  difficult  or  impos- 
sible, the  angiotribe  may  be  used  instead.  It  should  remain 
on  the  tissues  two  minutes  before  they  are  divided.  At  the 
end  of  the  hysterectomy  the  broad  and  round  ligament  stumps 
should  be  drawn  down  and  sutured  to  the  raw  edges  of  the 
vaginal  vault  and  the  longitudinal  incision  in  the  anterior 
vaginal  wall  closed.  Enough  gauze  (10  per  cent,  iodoform) 
should  be  introduced  into  the  peritoneal  cavity  to  keep  the 
intestines  and  omentum  away  from  the  wound,  and  the  vagina 
tightly  packed.  The  vaginal  gauze  is  removed  on  the  third 
day  and  a  vaginal  douche  of  boric  acid  solution  ( 3  j  to  Oj)  given 
twice  a  day  thereafter.  The  withdrawal  of  the  peritoneal 
gauze  is  begun  on  the  fourth  day,  a  few  inches  being  removed 
at  each  dressing  until  it  is  all  away,  usually  by  the  eighth  day. 
Any  granulation  tissue  in  the  vaginal  wound  should  be  cauter- 
ized every  other  day  with  silver  nitrate. 

Abdominal  Celiotomy. — The  preparation  of  the  patient  is 
begun  twenty-four  hours  before  operation.  The  bowels  are 
thoroughly  opened  and  all  hair  removed  from  the  vulva.  The 
abdomen  from  the  umbilicus  to  the  pubes  is  scrubbed  for  five 
minutes  with  tincture  of  green  soap,  rinsed  off  with  sterile 
water,  and  rescrubbed  for  two  minutes  with  Stewart's  solution, 
followed  by  a  cleansing  with  water.  A  protective  dressing  of 
sterile  gauze  is  applied.     The  same  preparation  of  the  field 


ABDOMINAL  CELIOTOMY  1^3 

of  operation  is  repeated  shortly  before  the  anesthesia  is 
begun,  and  the  protective  dressing  left  in  place  until  the 
patient  is  ready  for  operation.  There  is  no  final  scrubbing 
while  the  patient  is  under  the  anesthetic. 

The  hands  of  the  operator,  assistants,  and  nurses  are  prepared 
as  on  page  157  and  sterile  rubber  gloves  worn.  The  patient 
should  be  in  the  Trendelenburg  position  during  the  opera- 
tion. 

The  instruments  required  are  2  scalpels,  curved  and 
straight  scissors,  2  pairs  of  tissue  forceps,  large  and  small; 
'  6  pairs  of  small  artery  clamps,  3  pairs  of  large  artery  clamps, 
2  hysterectomy  clamps,  a  ligature  carrier,  needle-holder,  2 
wound  retractors,  12  self-retaining  abdominal  retractors,  a 
trowel  retractor,  small  and  large  needles,  and  suture  and 
ligature  material. 

The  incision  may  be  made  either  longitudinal  in  the  median 
line,  transverse  either  between  the  anterior  superior  iliac 
spines  (Pfannenstiel)  or  at  the  pubic  hair  line.  The  first  and 
second  are  preferable  for  large  tumors,  and  the  latter  when 
the  field  of  operation  lies  mostly  in  the  pelvis. 

Longitudinal  abdominal  celiotomy  through  skin,  subcutic- 
ular tissue,  and  fat  down  to  the  fascia  covering  the  recti 
muscles.  The  sheath  of  one  rectus  muscle,  generally  the 
right,  is  opened,  the  muscle  separated  from  the  linea  alba  and 
retracted  to  the  outer  side.  This  discloses  the  peritoneum, 
which  is  picked  up  with  two  pairs  of  artery  clamps,  care  being 
taken  not  to  include  underlying  intestines  or  omentum.  The 
peritoneum  is  then  incised  between  the  clamps  and  entrance 
to  the  abdominal  cavity  accomplished. 

Transverse  Abdominal  Incision  (Pfannenstiel). — A  straight 
incision  five  to  six  inches  in  length  is  made  between  the 
anterior  superior  iliac  spines.  This  extends  through  the 
skin,  fat,  and  fascia,  exposing,  the  recti  muscles.  The  upper 
and  lower  fascial  flaps  are  dissected  free  from  the  linea  alba 
and  the  recti  retracted,  disclosing  the  peritoneum,  which  is 
opened  in  a  vertical  direction. 


184     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

Transverse  Suprapubic  Incision  (Author's). — A  straight  in- 
cision two  to  three  inches  in  length  parallel  to  the  symphysis 
pubis  is  made  just  in  the  pubic  hair,  or  slightly  above  it  in 
the  transverse  fold.  The  skin,  subcuticular  tissues,  and 
fascia  are  incised,  exposing  both  recti  and  pyramidali 
muscles  (Fig.  93). 

The  fascia  is  dissected  free  from  the  linea  alba  and  muscle 
for  two  inches  above  and  below,  care  being  taken  not  to  injure 
the  pyramidali  muscles.    The  right  rectus  muscle  is  separated 


Fig.  93 


Transverse  suprapubic  incision. 


from  its  pyramldalis  and  from  the  linea  alba,  retracted  out- 
ward, the  pyramidalis  is  retracted  toward  the  middle  line,  and 
the  peritoneum  opened  (Fig.  94). 

This  incision  is  an  ideal  one  for  pelvic  surgery,  as,  being 
directly  over  and  parallel  to  the  pelvic  organs,  it  gives  a  better 
exposure  of  the  field  of  operation  than  a  median  longitudinal 
incision  of  twice  its  length  (Fig.  95) .  As  it  is  made  intermus- 
cular, the  danger  of  subsequent  hernia  is  minimized  and  the 
resulting  scar,  on  account  of  its  location,  leaves  little  to  be 
desired  from  a  cosmetic  standpoint  (Fig.  96). 


ABDOMINAL  CELIOTOMY 


185 


Fig.  94 


Transverse  suprapubic  incision. 
Fig.  95 


Transverse  suprapubic  incision. 


186     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

After  opening  the  peritoneum,  the  self-retaining  retractor 
of  Doyen  is  introduced  and  remains  in  place  until  the  intra- 
peritoneal work  is  finished.  Thorough  inspection  of  the  pelvic 
organs  is  now  made,  and  for  this  purpose  trowel  retractors 
will  be  found  very  useful.     They  may  be  passed  deep  into 


Fig.  96 


Transverse  suprapubic  incision  (ten  days  after  operation). 


the  pelvic  cavity,  affording  efficient  retraction  in  otherwise 
inaccessible  localities,  and  from  their  polished  surfaces  reflected 
light  may  be  thrown  in  any  direction,  giving  extremely  val- 
uable illumination  of  the  operative  field.  Careful  study  of  the 
pathological  lesion  present  is  now  made  and  the  appropriate 
operative  treatment  decided  upon. 


ABDOMINAL  CELIOTOMY  187 

Abdominal  Celiotomy  for  Retrodisplacements. — After 
freeing  the  uterus  from  adhesions,  the  round  Kgaments  may 
be  shortened  by  any  one  of  several  methods.  The  Kgaments 
lie  directly  in  front  of  tjie  tube  and  are  easily  recognized. 

Mann's  Method. — The  ligament  is  picked  up  with  a  large 
artery  clamp,  looped  twice  on  itself,  and  the  three  folds  sewed 
together. 

GofEe's  Method. — Each  ligament  is  folded  once  on  itself  a 
short  distance  from  the  uterus,  the  folds  sewed  together  and 
the  free  end  of  the  loop  sutured  to  the  fundus  just  in  front 
of  the  tube. 

The  normal  origin  of  the  round  ligament  is  from  the  fundus 
just  in  front  of  the  tube.  Occasionally  the  point  of  origin 
will  be  found  farther  down  on  the  uterus  toward  the  internal 
OS.  In  these  cases  the  shortening  is  accomplished  by  suturing 
the  ligament  to  its  proper  height  on  the  fundus. 

The  uterosacral  ligaments  may  be  shortened,  as  advocated 
by  Byford,  to  correct  the  retrodisplacements  by  drawing  the 
cervix  upward  and  backward.  This  is  always  desirable  when 
there  is  much  descent  of  the  cervix.  The  fundus  is  held  for- 
ward against  the  symphysis  pubis  by  the  trowel  retractor 
passed  deep  into  the  cul-de-sac  of  Douglas.  This  develops 
the  ligaments,  which  are  then  picked  up,  folded  on  them- 
selves, and  shortened  sufficiently  to  bring  the  cervix  to  its 
normal  height  in  the  pelvis.  For  these  operations  on  the 
ligaments  medium-sized  silk  or  linen  thread  as  suture  material 
is  used. 

In  cases  where  it  is  desirable  to  correct  the  retrodisplace- 
ment  by  ventral  fixation,  suspension,  or  round  ligament  sus- 
pension, one  of  the  following  methods  may  be  chosen : 

Kelly's  Operation. — The  fundus  is  brought  forward  and  two 
sutures  of  chromic  gut  are  carried  transversely  through  one- 
half  inch  of  uterine  tissue  at  the  level  of  the  Fallopian  tubes. 
These  sutures  lie  one-half  inch  apart  and  the  free  ends  pass 
through  the  peritoneum  one  inch  above  the  symphysis  pubis. 
They  are  then  tied  separately. 


188     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

Gilliam's  Operation. — "An  abdominal  incision  three  or  four 
inches  in  length  is  made  in  the  median  line  at  the  usual  site 
between  the  umbilicus  and  pubes.  The  adhesions  are  broken 
up  and  the  fundus  brought  forward.  With  a  finger,  thumb,  or 
a  pair  of  bullet  forceps,  the  broad  ligament  of  one  side  is 
seized  and  brought  to  the  opening.  By  lifting  up  the  anterior 
surface  of  the  broad  ligament  on  the  tip  of  a  finger  applied  to 
its  posterior  surface,  the  round  ligament  is  brought  into  view 
and  is  picked  up  either  between  the  thumb  and  finger  or  with 
a  bullet  forceps.  Selecting  a  point  one  inch  and  one-half  from 
the  uterus,  a  thread  is  passed  under  the  ligament  and  the  ends 
of  the  thread  are  brought  out  of  the  opening  and  secured  in  the 
bite  of  a  clamp  forceps,  which  is  laid  upon  the  surface  of  the 
abdomen.  The  other  ligament  is  sought  for  and  secured  in 
the  same  manner. 

"At  a  point  about  one  and  one-half  inches  above  the  pubes, 
the  peritoneum,  muscle,  and  fascia  at  one  edge  of  the  wound 
are  caught  up  by  a  volsella  and  pinned  together,  being  careful 
that  the  edges  of  these  layers  are  in  line.  Traction  is  now 
made,  and,  with  a  small  retractor,  the  skin  and  superficial  fat 
are  drawn  in  the  opposite  direction,  uncovering  the  fascia. 
With  a  narrow-bladed  knife,  or,  better,  with  the  perforating 
forceps  devised  for  the  purpose,  a  stab  wound  is  made  from  the 
surface  of  the  fascia  into  the  peritoneal  cavity,  the  instrument 
entering  about  one-half  inch  from  the  edge  of  the  abdominal 
incision,  and  passing  obliquely  downward  and  outward, 
emerging  on  the  peritoneum  one  inch  from  the  edge  of  the 
abdominal  incision. 

"If  the  perforating  forceps  is  used,  the  jaws  are  separated, 
and,  by  an  outward  movement  of  the  handle,  brought  into 
plain  view  at  the  large  opening.  The  thread  which  loops  the 
round  ligament  is  now  placed  in  the  jaws,  the  clamp  forceps 
removed,  and  the  perforating  forceps  withdrawn,  bringing 
with  it  the  thread  and  the  ligament.  If  a  knife  has  been 
used  to  make  the  perforation,  it  is  withdrawn  and  a  slender 
forceps  introduced,  with  which  the  thread  is  caught  up  and 


SALPINGOSTOMY  1§9 

the  ligament  drawn  into  place.  Now,  while  the  ligament  is 
held  taut,  with  its  loop  and  one-fourth  or  one-third  of  an  inch 
above  the  surface  of  the  fascia,  a  catgut  suture  is  passed 
through  it,  including  the  tissues  on  either  side,  and  back 
again,  where  it  is  tied.  This  is  cut  close  to  the  knot,  the  sus- 
pending thread  cut  on  one  side  close  to  the  ligament  and 
withdrawn,  and  the  volsella  and  retractor  removed.  The 
other  side  is  dealt  with  in  like  manner  and  the  abdominal 
incision  closed." 

General  Indications  of  Abdominal  Celiotomy.  —  For 
Procidentia. — The  uterosacral  ligaments  are  shortened  to 
bring  the  cervix  up  to  its  normal  level  in  the  pelvis,  and  round 
ligament  ventrosuspension  of  the  uterus  performed  by  Gil- 
liam's technique  to  hold  the  fundus  forward. 

Obphorrhaphy. — The  ovarian  ligament  is  picked  up  at  a 
point  midway  between  the  uterus  and  ovary  and  the  loop  thus 
formed  sewed  together  with  two  or  three  sutures  of  medium- 
sized  silk  or  linen  thread. 

Oophorectomy. — In  severing  the  ovary  entire  it  is  pulled 
strongly  upward,  developing  a  pedicle,  which  contains  the 
ovarian  artery.  This  pedicle  is  then  transfixed  and  ligated 
before  the  ovary  is  removed.  In  many  cases  it  is  found 
unnecessary  to  sacrifice  the  entire  ovary,  and  the  diseased 
portion  only  should  be  cut  away,  the  incision  being  closed 
with  a  continuous  suture  of  fine  catgut  or  silk. 

Salpingostomy. — Occluded  tubes  are  often  encountered,  and 
in  many  cases  do  not  call  for  complete  removal.  If  the  tube 
can  be  easily  separated  from  adhesions,  its  distal  end  may  be 
opened,  the  inverted  fimbria  freed,  and  the  entire  tube  saved. 
Where  this  is  not  practical  a  new  opening  may  be  made  as  near 
the  fimbriated  end  as  possible.  When  the  disease  does  not 
involve  the  entire  tube,  it  is  only  necessary  to  remove  the 
affected  portion.  The  remaining  stump,  even  though  it  be 
only  a  fraction  of  an  inch  in  length,  may  functionate  if  left 
patulous.  To  accomplish  this  end  a  small-grooved  director 
is  passed  into  its  lumen  and  the  tube  incised  for  one-half 


190     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

inch  along  its  dorsum.  With  a  small  needle  and  fine  suture 
material  the  mucous  and  serous  coats  of  the  tube  are  united 
around  the  new  opening. 

Salpingectomy. — The  tube,  separated  from  adhesions,  is 
drawn  strongly  up,  and  the  pedicle  thus  developed  in  the 
broad  ligament  quilted  off  with  one  continuous  ligature  from 
distal  to  proximal  end.  When  the  uterine  cornu  is  reached 
the  ligature  surrounds  the  tube  close  to  the  uterus  and  the 
final  knot  is  tied  before  cutting  away  the  tube.  In  some  cases 
the  uterine  portion  of  the  tube  should  be  removed  as  well. 
This  is  accomplished  by  free  dissection  into  the  horn  of  the 
uterus,  removing  the  tube  entire,  and  the  uterine  wound  is 
then  closed  by  interrupted  sutures. 

Abdominal  Hysterectomy. — Either  complete  removal  of  the 
uterus,  or  removal  just  above  the  vaginal  portion  of  the  cervix, 
may  be  performed,  according  to  the  requirements  of  the  case. 
The  latter  operation  is  with  many  the  one  of  choice  in  all  but 
malignant  cases  (Fig.  97). 

Supravaginal  Removal. — The  fundus  is  grasped  with  the 
heavy  traction  forceps  and  drawn  strongly  up  out  of  the  pelvis. 
The  peritoneal  reflection  from  the  bladder  to  the  uterus  is 
divided  transversely,  from  broad  ligament  to  broad  ligament, 
and  the  bladder  freed  from  the  uterus,  by  blunt  dissection. 
The  broad  ligaments  are  now  clamped  with  the  heavy 
hysterectomy  clamps,  from  the  infundibulopelvic  ligament 
to  the  cervix,  at  the  desired  level  of  amputation,  and  uterus  and 
appendages  cut  away.  The  cervical  stump  is  caught  with  the 
small  traction  forceps,  and  two  or  three  sutures  bring  together 
its  raw  edges.  First  one  broad  ligament  clamp  and  then  the 
other  is  removed,  each  ovarian  and  uterine  artery  being  ligated 
separately.  The  round  ligament  stumps  are  drawn  down  and 
sutured  to  the  cervix,  and  the  anterior  and  posterior  folds  of 
the  broad  ligament  are  sutured  together,  covering  in  all  raw 
surfaces  from  the  infundibulopelvic  ligaments  to  the  cervix. 
The  stump  of  the  cervix  is  covered  by  suturing  the  peritoneal 
reflection  from  the  bladder  to  the  peritoneum  on  the  posterior 


SUPRAVAGINAL  REMOVAL 


191 


aspect  of  the  cervix.    This  covering  in  of  the  raw  surfaces  by 
uniting  peritoneum  over  them  may  be  done  with  a  continuous 


Fig.  97 


Operation  of  supravaginal  hysterectomy,  seen  from  the  front.  Second  stage. 
The  outer  part  of  the  broad  ligament  is  divided  on  each  side.  The  anterior  peri- 
toneal flap  is  stripped  down  and  held  by  two  pressure  forceps.  One  ligature  is 
placed  on  each  uterine  artery.  A  second  ligature  is  passed  through  the  broad  liga- 
ment, just  within  it,  ready  for  subsequent  use.  LOA,  ligature  on  ovarian  artery; 
L/^L,  ligature  on  round  ligament;  />[//!,  ligature  on  uterine  artery;  O,  ovary;  OA, 
ovarian  artery;  FP,  anterifir  flaj)  of  peritoneum.      (Galabin.) 

suture,  running  from  one  infundibulopelvic  hgament  to  the 
other.     As  the  cervical  stump  is  reached  the  suture  passes 


192     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

through  it  several  times,  thus  holding  it  in  contact  with 
the  peritoneal  covering  and  obliterating  the  dead  space 
(Fig.  99). 

Fig.  98 


Supravaginal  hysterectomy,  seen  from  the  front.  Third  stage.  The  uterus  has 
been  cut  away.  The  ligature  on  each  side,  for  stitching  the  anterior  peritoneal  flap 
over  the  uterine  artery,  is  passed  and  ready  for  tying.  LOA,  ligature  on  ovarian 
artery;  LRL,  ligature  on  round  ligament;  LUA,  ligature  on  uterine  artery;  O, 
ovary;  FP,  anterior  flap  of  peritoneum.      (Galabin). 


Complete  Removal. — The  steps  of  this  operation  are  the 
same  as  for  supravaginal  removal,  with  the  following  excep- 
tion : 

When  the  uterus  is  cut  away,  instead  of  leaving  the  cervical 
stump  behind,  the  cervix  is  freed  from  its  vaginal  attachment 
and  removed  entire  with  the  uterus.  In  some  cases  it  is 
easier  to  perform  a  supravaginal  removal  first,  taking  out  the 


REMOVAL  OF  PEDUNCULATED  TUMORS 


193 


cervix  afterward.  Some  operators  prefer  to  quilt  off  the 
broad  ligaments  with  a  continuous  ligature,  as  in  vaginal 
hysterectomy,  instead  of  using  clamps 


Fig.  99 


Supravaginal  hysterectomy,  seen  from  the  front.  Fourth  stage.  The  continuous 
suture,  uniting  the  peritoneum,  is  nearly  completed.  AH  the  main  ligatures  are  cut 
short,  except  that  on  the  right  ovarian  artery.  LOA,  ligature  on  ovarian  artery; 
LRL,  ligature  on  round  ligament;  LUA,  ligature  (second)  on  uterine  artery; 
O,  ovary;  S,  continuous  sutiire;  N,  needle.     (Galabin). 


Removal  of  Pedunculated  Tumors. — The  tumor  is  separated 
from  adhesions,  the  pedicle  transfixed,  ligated,  and  cut.  In 
fibroids  too  large  to  be  delivered  through  the  abdominal  wound 
the  pedicle  may  be  clamped,  the  tumor  removed  by  morcel- 
lation,  and  the  pedicle  then  ligated. 
13 


194     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

Myomectomy. — Is  performed  for  subperitoneal  and  inter- 
stitial fibroids.  The  uterine  tissue  over  the  fibroid  is  incised, 
the  tumor  enucleated  and  the  incision  in  the  uterus  united 
with  interrupted  sutures. 

Closure  of  the  Abdominal  Incision. — Inclosing  the  incision 
through  the  abdominal  wall  after  operation  three  structures 
need  accurate  apposition  in  order  to  restore,  as  nearly  as 
possible,  the  normal  anatomical  relations.  These  are  the  peri- 
toneum, fascia,  and  skin.  The  muscles,  provided  they  have 
been  subjected  to  no  further  traumatism  than  the  necessary 
displacement  or  separation  of  their  fibers,  require  no  retaining 
sutures. 

In  holding  the  tissues  together  until  union  has  taken  place, 
it  is  desirable  to  use  as  few  sutures  as  possible,  for  every  one 
introduced  into  the  wound  is  a  foreign  body,  increasing  the 
chance  of  infection.  The  sutures  should  be  so  introduced  as  to 
accomplish  their  purpose  without  strangulation  of  the  tissues 
which  they  unite,  for  where  the  sutures  are  tied  in  the  wound 
the  nutrition  of  the  tissues  they  include  is  interfered  with, 
and  atrophy,  if  not  actual  necrosis,  results.  This  is  particu- 
larly true  of  the  fascia,  more  poorly  nourished,  as  it  is,  than 
either  the  peritoneum  or  the  skin.  Moreover,  the  tying  of 
knots  in  the  wound  greatly  increases  the  amount  of  foreign 
material  introduced  that  later  must  become  absorbed  or 
encysted. 

A  careful  consideration  of  the  above  facts  and  theories  has 
led  the  author  to  adopt  the  following  method  of  closing  the 
abdominal  wound  in  the  majority  of  celiotomies,  with  most 
excellent  results  (Fig.  100). 

Technique. — The  peritoneum  is  brought  together  by  a  con- 
tinuous suture  of  fine  silk  or  kangaroo  tendon.  The  fascia  is 
united  by  a  running  quilted  stitch  of  large-sized  silk-worm 
gut,  drawing  the  raw  edges  together  without  undue  tension, 
and  instead  of  being  tied,  the  ends  are  brought  out  through 
the  skin  and  left  long  near  the  angles  of  the  wound. 

The  incision  in  the  skin  is  closed  by  a  continuous  subcutic- 


CLOSURE  OF  THE  ABDOMINAL  INCISION  195 

ular  stitch  of  silkworm  gut,  and  the  ends  are  also  brought  out 
long  through  the  skin  near  the  angles  of  the  wound,  but  on  the 
opposite  sides  from  the  fascial  stitch. 

A  firm  roll  of  gauze,  one  inch  thick  and  slightly  longer  than 
the  wound,  is  now  laid  over  it,  and  over  this,  at  each  end,  the 
skin  and  fascial  stitches  are  tied  together  in  a  single  bowknot, 
just  tight  enough  to  take  up  any  slipping  that  may  have 

Fig.  100 


Author's  method  of  closing  the  abdominal  wound. 

occurred  in  the  fascial  stitch  since  its  introduction.  At  the 
first  dressing  on  the  second  day  the  gauze  between  these 
knots  is  cut  out  so  as  to  allow  subsequent  daily  inspection  of 
the  wound. 

At  the  end  of  the  first  week  the  knots  are  untied,  releasing 
the  remaining  ends  of  the  gauze  roller,  and  the  skin  stitch  is  cut 
off  at  one  end  and  drawn  out.  One  week  later  the  fascial 
stitch  is  removed  in  a  similar  manner,  thus  leaving  no  suture 


196     GENERAL  GYNECOLOGICAL  OPERATIVE  TECHNIQUE 

material  behind  in  the  wound    between  the  peritoneum  and 
skin. 

In  case  there  is  failure  on  the  part  of  the  wound  to  heal  by 
primary  union,  the  skin  stitch  should  be  withdrawn  and  the 
fascial  incision  inspected.  If  this  shows  infection,  or  if  the 
infection  is  under  the  fascia,  its  edges  can  be  readily  separated 
by  loosening  the  suture  without  removing  it,  and  proper 


Fig.  101 


Abdominal  dressing  for  laparotomy  cases. 

drainage  secured.  Later,  when  the  infection  has  subsided 
and  union  begun,  the  edges  of  the  fascia  can  again  be  drawn 
together  and  good  approximation  obtained.  Thus,  the 
introduction  of  secondary  sutures  to  close  the  separation  in 
the  fascia  so  often  observed  following  suppurating  wounds, 
and  such  a  frequent  cause  of  postoperative  hernia,  is  avoided, 
saving  much  annoyance  to  both  patient  and  surgeon. 


CARE  OF   THE  ABDOMIXAL   WOUND  197 

Dressing  of  the  Abdominal  Wound. — The  skin  surface 
around  the  wound  is  dusted  with  a  dry  aseptic  powder,  and  a 
firm  gauze  pad  covers  the  wound  area.  Over  this  is  placed  a 
covering  of  thin  rubber  tissue,  and  the  whole  dressing  is  held 
in  place  with  overlapping  strips  of  adhesive  plaster  two  inches 
in  width.  At  the  lower  end  of  the  dressing  the  last  strip  of 
plaster  is  applied  to  the  skin  over  the  symphysis  and  out  on  to 
the  groins,  sealing  the  dressing  below  to  prevent  possible 
contamination  by  urine  or  feces  (Fig.  101). 

Subsequent  Care  of  the  Abdominal  Wound. — On  the 
second  day  after  operation  the  dressing  is  opened  by  cutting 
the  adhesive  plaster  and  rubber  tissue  in  the  middle  line. 
The  two  flaps  are  turned  to  either  side,  the  rubber  tissue 
preventing  them  from  sticking  to  the  gauze.  The  gauze  is 
removed  and  the  wound  inspected.  Fresh  gauze  is  then 
applied,  the  adhesive  plaster  covering  brought  together,  and 
either  laced  or  held  by  short  strips  of  plaster.  The  wound  is 
inspected  each  day  until  the  dressing  is  finally  removed. 


QUESTIONS. 


Describe  the  development  of  the  genital  tract. 

Mention  the  more  common  errors  of  development. 

Name  the  external  organs  of  generation. 

Describe  the  labia  majora. 

Describe  the  labia  minora. 

Describe  the  vestibule. 

Describe  the  glands  of  Bartholin. 

Describe  the  clitoris. 

Describe  the  hymen. 

Describe  the  vagina. 

What  are  the  internal  organs  of  generation  ? 

Describe  the  uterus. 

Describe  its  peritoneal  covering. 

What  is  the  chief  function  of  the  broad  ligaments  ? 

What  are  the  supports  of  the  uterus  ? 

Describe  the  uterovesical  ligaments. 

Describe  the  uterosacral  ligaments. 

Describe  the  round  ligaments. 

What  important  changes  take  place  in  the  uterus  at  puberty  ? 

What  changes  occur  in  the  uterus  at  menstruation  ? 

Describe  the  changes  occurring  at  the  menopause. 

Describe  the  Fallopian  tubes. 

With  what  variety  of  epithelium  are  they  lined? 

Describe  the  ovaries. 

Describe  the  ovarian  ligaments. 

What  is  a  Graafian  foUicle,  and  how  does  it  mature? 

Define  corpus  luteum. 

How  are  the  ovaries  held  in  place?  ^ 

Discuss   the   relations   of  the   pelvic   organs  with   the   neighboring 
\dscera. 

What  are  the  m^ore  common  causes  of  diseases  among  women  ? 

What  precautions  should  be  observed  during  menstruation  ? 

Give  the  leading  questions  necessary  in  taking  a  gynecological  history. 

How  would  you  make  an  abdominal  examination  ? 

Describe  the  technique  of  a  vaginal  examination. 

Describe  the  bimanual  examination. 

State  the  importance  of  making  a  rectal  examination. 

How  would  you  use  the  vaginal  speculum? 

"W^at  are  the  principal  malformations  of  the  external  genitalia.,  and 
how  do  they  arise  ? 
(198) 


QUESTIONS  199 

Describe  the  different  forms  of  hymen. 
To  what  is  hermaphroditism  due? 
Give  the  pathology  of  vulvitis. 
What  glands  are  liable  to  become  infected  ? 
Give  the  etiology  of  vulvitis. 

What  are  the  common  causes  of  infantile  vulvitis? 
Give  the  objective  symptoms  of  vulvitis. 
Give  the  subjective  s3^mptoms. 
Describe  the  different  varieties  of  vulvitis. 
How  would  you  diagnosticate  a  case  ? 
Give  the  treatment  of  acute  vulvitis. 
Give  the  treatment  of  chronic  vulvitis. 
What  is  the  treatment  of  condylomata  of  the  vulva? 
What  is  pruritus  vulva?? 
Give  the  symptoms  of  pruritus  vulv£e. 
What  is  the  treatment? 
Define  kraurosis  vulva?. 
Give  the  treatment. 

What  is  the  etiology  of  hematoma  of  the  vulva? 
What  is  the  pathology? 
Distinguish  from  hernia  of  the  vulva. 
Give  the  symptoms. 

What  is  the  treatment  of  hematoma  of  the  vulva? 
What  is  the  pathology  of  varicocele  of  the  vulva? 
What  is  the  treatment  ? 

What  is  the  most  common  form  of  cyst  of  the  vulva? 
Describe  the  pathology. 
Give  the  etiology  of  cyst  of  the  vulva. 
What  are  the  symptoms? 
Describe  the  treatment  of  cyst  of  the  vulva. 
When  should  complete  removal  of  the  cyst  wall  be  practised? 
What  is  elephantiasis  of  the  vulva  ? 
What  three  forms  are  recognized? 
Give  the  pathology  of  elephantiasis  of  the  vulva. 
What  is  the  most  common  benign  growth  of  the  vulva  ? 
Give  the  diagnosis. 
What  is  the  treatment? 

What  forms  of  malignant  tumor  develop  on  the  vulva? 
What  is  their  pathology? 
Describe  the  symptoms. 

Give  the  treatment  for  carcinoma  of  the  vulva. 
What  is  the  prognosis  of  sarcoma  of  the  vulva? 

How  would  you  distinguish  between  hernia  and  a  newgrowth  forma- 
tion of  the  vulva"  ? 

What  is  the  treatment  of  vulval  hernia? 
What  are  the  malformations  of  the  \'agina? 
What  varieties  of  atresia  are  met  with? 
Describe  atresia  hymenal  is. 
Describe  atresia  vaginalis.    Atresia  cer\icalis. 
Describe  hour-glass  contraction  of  the  vagina. 


200  QUESTIONS 

What  are  the  more  common  diseases  of  the  vagina  ? 
What  is  the  pathology  of  vaginitis  ? 
Give  the  etiology  of  vaginitis. 
Describe  the  different  varieties  of  vaginitis. 
Give  the  symptoms  of  acute  vaginitis. 
Describe  the  diagnosis. 
Outhne  the  treatment  of  acute  vaginitis. 
What  is  vaginismus? 
Give  its  etiology. 
Describe  the  sj^mptoms. 
What  is  the  treatment? 
Give  the  causes  of  dyspareunia. 
What  are  the  more  common  tumors  of  the  vagina  ? 
Describe  carcinoma  of  the  vagina. 
Discuss  the  diagnosis. 

What  are  the  malformations  of  the  uterus? 
Describe  uterus  bicornis. 
Describe  the  infantile  t3^pe  of  uterus. 
What  is  the  etiology? 
Give  the  treatment. 

What  is  the  significance  of  the  non-appearance  of  menstruation? 
Describe  atrophy  of  the  cervix. 

Describe  hypertrophy  of  the  A^aginal  portion  of  the  cervix. 
Distinguish  between  hypertrophy  and  hj^perelongation  of  the  cervix. 
What  is  the  pathology  of  cervical  laceration  ? 
Etiology  of  laceration  of  the  cervix? 
What  are  the  immediate  symptoms  of  laceration? 
What  are  the  late  symptoms  of  laceration? 

Describe  the  treatment  of  the  different  forms  of  cervical  laceration. 
Define  cervical  catarrh. 
What  is  its  pathologj^? 
Discuss  the  diagnosis. 
What  is  the  treatment  ? 
Define  endometritis. 

What  is  the  pathology  of  acute  endometritis? 
What  is  the  etiology  of  acute  endometritis? 
Give  the  symptoms  of  gonorrheal  endometritis. 
How  would  you  determine  the  diagnosis  ? 
W^hat  are  the  sjmiptoms? 
Describe  the  treatment. 
What  is  septic  puerperal  endometritis? 
Give  the  sj^mptoms. 
Give  the  diagnostic  signs. 
What  is  putrid  endometritis  ? 
Give  the  symptoms. 
Outline  the  treatment. 

How  would  you  differentiate  between  septic  puerperal  endometritis 
and  putrid  endometritis? 

What  is  the  pathology  of  chronic  endometritis? 
Give  its  etiology. 


QUESTIONS  201 

What  are  the  symptoms? 

Discuss  the  use  of  the  curette  in  the  various  forms  of  endometritis. 
What  are  the  contra-indications  to  its  use  ? 
What  is  metritis? 

Distinguish  between  the  acute  and  chronic  variety. 
Give  the  pathology  of  chronic  metritis. 
Give  the  etiology  of  chronic  metritis. 

Describe  the  precautions  to  be  taken  to  avoid  its  occurrence. 
What  are  the  symptoms  of  chronic  metritis? 
What  are  the  effects  of  chronic  metritis  on  conception? 
Describe  the  diagnosis  of  chronic  metritis. 
Distinguish  from  early  pregnancy. 
Give  the  treatment  in  a  case  of  chronic  metritis. 
Is  tuberculosis  of  the  uterus  of  frequent  occurrence? 
What  part  of  the  uterus  is  most  commonly  involved  ? 
Give  the  symptoms. 
Define  subinvolution  of  the  uterus. 
What  is  its  pathology? 
Give  the  symptoms. 

Distinguish  between  subinvolution  and  superinvolution. 
"V\Tiat  is  the  most  common  cause  of  superinvolution  ? 
What  is  the  treatment  of  subinvolution? 

Discuss  the  value  of  ergot,  and  give  a  contra-indication  to  its  use. 
Define  atresia  of  the  genital  canal. 

What  are  the  different  points  at  which  obstruction  may  occur  ? 
What  is  the  most  common  variety  ? 
Give  the  symptoms  of  atresia  hymenalis. 
What  is  its  treatment? 

What  are  the  two  principal  types  of  malignant  disease  of  the  uterus  ? 
Give  an  example  of  each. 

What  are  the  symptoms  of  carcinoma  of  the  cervix? 
Give  its  pathology. 
In  what  three  ways  may  it  begin  ? 
Discuss  the  treatment  of  an  inoperable  case. 
Is  carcinoma  of  the  fundus  of  frequent  occurrence? 
What  is  its  pathology  ? 
Give  the  principal  diagnostic  features. 
With  what  conditions  is  it  most  often  confused  ? 

What  is  the  principal  point  of  difference  between  carcinoma  and 
sarcoma  ? 

Describe  the  treatment  of  sarcoma  of  the  fundus. 

Does  the  growth  ever  occur  in  the  cervix? 

Define  deciduoma  malignum. 

What  is  its  pathology? 

Give  its  etiology. 

When  is  it  most  liable  to  develop? 

State  the  symptoms. 

How  may  an  absolute  diagnosis  be  made? 

What  is  the  duration  of  the  disease? 

What  is  the  prognosis? 


202  QUESTIONS 

Give  the  treatment. 

What  is  the  most  frequent  form  of  benign  tumor  met  with  in  the 
uterus  ? 

At  what  age  are  they  most  often  seen  ? 

Contrast  with  cancer  so-called. 

How  do  all  fibromyomata  begin? 

Describe  their  growth. 

How  are  they  influenced  by  the  puerperium? 

Does  arrest  ever  occur  at  the  menopause  ? 

What  are  the  three  recognized  varieties? 

Which  variety  is  most  liable  to  change  the  size  of  the  uterus,  and 
which  its  position? 

What  are  some  of  the  changes  that  may  take  place  in  a  fibroid  during 
its  growth? 

Does  suppuration  ever  occur,  and  what  is  its  cause? 

On  what  do  the  s3^mptoms  of  fibromyomata  depend  ? 

Give  the  more  common  symptoms. 

What  influence  do  they  have  on  conception? 

What  effect  do  the  fibromyomata  have  on  menstruation? 

Is  amenorrhea  common  with  the  fibroids? 

Mention  the  more  common  complications  they  may  cause  during 
pregnancy. 

What  is  the  most  common  error  in  diagnosis? 

Give  the  differential  diagnosis  between  fibrom3'oma  and  pregnancy. 

Discuss  the  A-alue  of  myomectomy. 

What  are  the  indications  that  call  for  the  operative  removal  of  the 
tumor? 

Of  what  benefit  is  curettage  in  these  cases? 

Give  the  pathology  of  adenomyoma. 

Define  adenomyoma  uteri. 

What  are  the  symptoms? 

How  should  these  tumors  be  treated? 

Define  uterine  polyp. 

Give  the  pathology  of  these  growths. 

Give  the  symptoms  of  uterine  polyp. 

W^hat  is  the  treatment  ? 

What  is  the  most  important  pathological  condition  met  with  in  the 
Fallopian  tubes? 

Give  the  pathology  of  acute  salpingitis. 

Describe  the  formation  of  a  tuboovarian  abscess. 

Does  spontaneous  rupture  of  a  pyosalpinx  ever  occur  ? 

In  what  manner  may  perforation  and  evisceration  occur? 

How  does  salpingitis  cause  sterility? 

Give  the  etiology  of  salpingitis. 

What  is  the  most  common  infecting  medium? 

What  are  the  symptoms  of  acute  salpingitis  ? 

Give  the  diagnosis. 

How  would  you  diagnosticate  from  acute  appendicitis  ? 

Discuss  the  treatment  of  acute  salpingitis. 

Of  pyosalpinx. 


QUESTIONS 


203 


Of  tuboovarian  abscess. 
Of  chronic  salpingitis. 

Discuss  the  indications  for  the  resection  of  a  diseased  tube  rather 
than  its  complete  renlo^•al. 

What  are  the  infectious  granulomata  that  affect  the  tubes? 

Give  their  pathology. 

Is  pain  a  constant  sj^mptom? 

Give  the  neoplasms  which  may  develop  in  the  tubes. 

Define  ectopic  gestation. 

Give  its  pathology. 

AVhat  are  the  different  varieties  ? 

Describe  the  most  common  one. 

What  is  the  rule  in  regard  to  the  hfe  of  the  fetus  ? 

State  the  different  ways  in  which  termination  may  take  place. 

Describe  tubal  twin  pregnancy. 

What  is  the  etiology? 

Give  the  symptoms  of  tubal  pregnancy  before  rupture. 

Give  the  symptoms  of  tubal  pregnancv  after  rupture. 

Describe  the  diagnosis  before  rupture.' 

After  rupture. 

Discuss  the  treatment  before  rupture. 

Discuss  the  treatment  after  rupture. 

Define  ovaritis. 

What  is  its  importance? 

Describe  the  chronic  variety. 

What  are  the  symptoms  of  chronic  ovaritis? 

Name  the  more  common  tumors  of  the  ovary. 

In  what  three  ways  do  these  tumors  arise  ? 

Give  the  diagnosis  of  chronic  ovaritis. 

W^hat  is  the  treatment  of  acute  ovaritis? 

What  is  the  treatment  of  chronic  ovaritis? 

What  are  the  displacements  of  the  ovary? 

Which  one  is  most  commonly  met  with? 

Give  the  pathology  of  prolapse  of  the  ovary. 

Mention  some  of  the  more  important  etiological  factors. 

What  are  the  S3^mptoms? 

How  would  you  make  a  diagnosis  in  a  case  of  adherent  prolapse? 

Describe  the  treatment. 

Give  the  pathology  of  the  simple  cysts. 

Of  the  adenomata. 

Of  the  papillomata. 

Which  variety  attain  the  largest  size? 

To  what  complications  are  they  liable? 

Describe  the  dermoid  variety. 

What  is  an  ovarian  teratoma? 

What  are  the  non-malignant  tumors  of  the  ovary? 

What  are  the  malignant  involvements? 

Describe  the  parovarian  cysts. 

What  are  the  symptoms? 

Distinguish  parovarian  from  simple  cyst. 


204  QUESTIONS 

How  would  you  diagnosticate  an  ovarian  cyst  ? 

Give  the  differential  diagnosis  between  ascites  and  ovarian  cyst. 

What  is  the  treatment  of  the  ovarian  tumors? 

Define  pelvic  peritonitis. 

What  are  the  two  varieties? 

Give  the  pathology. 

Describe  the  symptoms  of  acute  pelvic  peritonitis. 

What  is  the  etiology  ? 

What  are  the  two  principal  avenues  of  infection  ? 

State  the  chief  diagnostic  features  of  the  disease. 

What  is  the  ordinary  cause  of  a  case  of  pelvic  peritonitis? 

Describe  the  treatment. 

What  are  the  indications  for  operative  treatment? 

Define  pelvic  hematocele. 

What  is  its  pathology  ? 

What  is  its  most  frequent  cause? 

What  are  the  symptoms? 

Discuss  the  diagnosis. 

Give  the  treatment. 

Define  pelvic  abscess. 

What  is  its  pathology  ? 

Give  its  etiology. 

What  are  the  symptoms? 

Discuss  the  diagnosis. 

Give  the  treatment  for  this  condition. 

Describe  normal  menstruation. 

At  what  two  periods  in  life  is  it  suspended  ? 

Wliat  is  the  average  age  of  onset  ? 

How  does  this  vary  in  different  climates? 

Describe  premature  menstruation. 

Delayed  menstruation. 

What  is  vicarious  menstruation? 

Define  amenorrhea. 

Give  the  pathology  of  amenorrhea. 

Give  the  etiology  of  amenorrhea. 

Of  what  is  it  often  a  symptom? 

Give  the  treatment. 

Define  menorrhagia. 

What  is  its  etiology  ? 

Give  the  treatment. 

Define  metrorrhagia. 

Of  what  condition  is  metrorrhagia  often  the  first  sign? 

Define  dysmenorrhea. 

What  is  the  pathology  of  dysmenorrhea? 

What  is  its  etiology? 

Discuss  the  two  recognized  theories  of  dysmenorrhea. 

What  are  the  symptoms  of  dysmenorrhea? 

Give  the  treatment. 

What  is  the  normal  position  of  the  uterus? 

How  is  this  position  maintained  ?■ 


QUESTIONS  205 

Mention  some  of  the  causes  of  variations  in  position  within  physio- 
logical limits. 

Name  the  most  important  supporting  ligaments  of  the  uterus. 

Describe  their  action. 

What  is  the  first  step  in  all  displacements  ? 

What  is  the  most  important  factor  in  causing  retrodisplacements  of 
the  uterus? 

Describe  the  position  of  the  cervix  in  retroflexion. 

Describe  the  position  of  the  fundus  in  retroflexion. 

What  are  the  minor  displacements  of  the  uterus  ? 

What  are  the  major  displacements? 

What  is  the  pathology  of  the  retrodisplacements? 

Give  the  etiology  of  the  retrodeviations. 

What  are  the  symptoms  of  retroflexion? 

Give  the  diagnosis. 

Describe  the  bimanual  method  of  examination. 
-    How  would  you  distinguish  between  retroflexion  and  a  small  fibroid 
in  the  posterior  uterine  wall? 

What  is  the  treatment  of  uncomplicated  retroflexion  ? 

Describe  the  vaginal  method  of  replacement. 

Describe  the  bimanual  method. 

What  is  the  action  of  the  retroversion  pessary  ? 

How  is  it  held  in  place  ? 

How  would  you  introduce  it? 

Give  the  treatment  for  a  case  of  adherent  retroflexion. 

What  are  the  most  used  operations  for  the  treatment  of  retroflexion? 

Give  the  operative  indication. 

Discuss  the  relative  merits  of  the  various  operations. 

What  is  the  importance  of  the  lateral  deviations  of  the  uterus  ? 

What  are  the  downward  displacements? 

Distinguish  between  them. 

Give  the  pathology  of  prolapsus  uteri. 

Is  prolapse  common  in  cases  of  complete  perineal  laceration  ? 

Give  the  pathology  of  procidentia. 

Give  the  diagnosis. 

Give  the  etiology. 

What  is  the  first  step  in  the  descent  of  the  uterus? 

What  are  the  symptoms? 

What  are  the  symptoms  of  traumatic  prolapse? 

Describe  the  non-operative  treatment. 

Give  the  operative  treatment. 

Define  inversion  of  the  uterus. 

What  is  its  pathology? 

What  is  its  etiology? 

What  are  the  symptoms? 

Give  the  diagnosis. 

Discuss  the  tn.'atment? 

Distinguish  between  inversion  and  uterine  polypus. 

What  is  hernia  of  the  uterus? 

Define  anteflexion. 


206  QUESTIONS 

Give  its  pathology. 

What  is  the  etiology  ? 

Give  the  sj^mptoms. 

How  would  you  diagnosticate  a  case  ? 

Discuss  the  treatment. 

Distinguish  between  anteflexion  and  infantile  uterus. 

What  is  the  effect  of  pregnancy  on  anteflexion? 

What  is  the  effect  of  pregnancy  on  the  infantile  uterus  ? 

Give  the  operative  treatment  for  a  case  of  anteflexion. 

What  is  the  menopause? 

What  is  the  average  period  of  active  menstrual  life  ? 

At  what  age  does  it  commonly  stop  ? 

Describe  the  most  common  manner  of  cessation. 

What  are  the  causes  of  premature  cessation  ? 

What  morbid  conditions  are  apt  to  develop  at  this  time? 

Give  the  well-recognized  symptoms  of  the  climacteric. 

What  is  the  importance  of  irregular  hemorrhages  at  this  time  ? 

Give  the  differential  diagnosis  between  premature  menopause  and 
pregnancy. 

What  is  the  treatment? 

What  do  you  understand  by  relaxation  of  the  vaginal  outlet? 

Give  its  pathology. 

What  is  the  etiology? 

Describe  the  S3^mptoms. 

How  would  you  diagnosticate  this  condition? 

What  are  the  factors  that  should  determine  operative  repair  ? 

Describe  the  different  varieties  of  perineal  laceration. 

Give  the  pathology. 

Discuss  the  etiology. 

Give  the  symptoms. 

Describe  the  condition  existing  in  complete  laceration  of  the  peri- 
neum. 

What  is  the  treatment? 

Define  cystocele. 

Give  its  pathology. 

How  does  the  presence  of  a  cystocele  affect  micturition? 

What  are  the  remote  effects  on  the  kidneys  ? 

Discuss  the  etiology  of  cystocele. 

What  are  the  sj^mptoms? 

Give  the  diagnosis. 

What  is  the  palliative  treatment? 

Describe  the  pessary  treatment. 

When  should  operative  treatment  be  carried  out? 

Define  rectocele. 

What  is  its  pathology? 

Give  its  etiology. 

What  are  the  symptoms? 

Discuss  its  bearing  on  prolapse  of  the  uterus. 

What  is  the  treatment  of  rectocele? 

Define  genital  fistula. 


QUESTIONS  207 

Mention  the  different  varieties. 

What  is  the  pathology? 

What  is  the  etiology  of  vesicovaginal  fistula? 

Give  the  symptoms. 

Dg3S  spontaneous  cure  ever  result  ? 

What  are  the  indications  for  operative  treatment? 

Define  sterility. 

State  the  difference  between  absolute  and  relative  sterility. 

What  is  the  etiology  of  sterility? 

What  is  the  most  fertile  period  of  a  woman's  life? 

What  congenital  defects  are  often  present  in  sterility  ? 

Describe  the  treatment. 

What  are  the  minor  gynecological  operations  ? 

What  are  the  major  gynecological  operations? 

Describe  the  preparation  of  a  patient  for  a  vaginal  operation. 

What  are  the  indications  for  curettage? 

What  instruments  are  required  ? 

Describe  dilatation  of  the  cervix. 

Describe  the  operation  of  curettage. 

What  precautions  should  be  taken  to  prevent  laceration  of  the  cervix 
during  divulsion? 

What  is  the  effect  of  too  rapid  dilatation? 

What  are  the  indications  for  packing  the  uterus  after  curettage? 

What  material  would  you  use? 

How  should  it  be  introduced  into  the  uterus? 

When  should  it  be  removed? 

Describe  the  operation  for  imperforate  hymen. 

What  is  the  after-treatment? 

Define  trachelorrhaphy. 

What  are  the  indications  for  repair  of  the  cervix? 

Describe  the  operation  of  trachelorrhaphy. 

What  are  the  indications  for  amputation  of  the  cervix? 

Describe  the  operation. 

Describe  an  operation  for  cystocele. 

Give  the  indications  for  perineorrhaphy. 

Describe  one  of  the  more  common  operations. 

Describe  an  operation  for  the  secondary  repair  of  complete  tear  of  the 
perineum. 

What  is  the  after-treatment  of  a  case  where  perineorrhaphy  has  been 
performed? 

Describe  an  operation  for  vesicovaginal  fistula. 

Should  the  bladder  be  subsequently  drained,  and,  if  so,  for  how  long  a 
period? 

Describe  an  operation  for  vesico-uterine  fistula. 

Describe  an  operation  for  uretero vaginal  fistula. 

Discuss  the  reluti\'e  advantages  of  the  vaginal  and  abdominal  methods 
of  approach. 

Describe  the  repair  of  a  rectovaginal  fistula. 

Give  the  after-treatment. 

Describe  the  operation  of  anterior  vaginal  celiotomy. 


208  QUESTIONS 

What  treatment  of  the  pelvic  organs  may  be  carried  out  through  this 
incision  ? 

Describe  a  method  of  correcting  retrodisplacements  through  this 
incision. 

Describe  the  operation  of  posterior  vaginal  celiotomy. 

Contrast  its  field  of  usefulness  as  compared  with  that  of  anterior 
vaginal  celiotomy. 

Mention  some  of  the  indications  for  vaginal  hysterectomy. 

Describe  the  operation. 

What  precautions  should  be  taken  to  avoid  injury  to  the  ureters? 

Describe  the  preparation  of  a  patient  for  abdominal  celiotomy. 

Give  the  technique  of  the  median  line  abdominal  incision. 

Give  the  technique  of  the  transverse  abdominal  incision. 

Discuss  the  relative  merits  of  the  transverse  and  median  line  incisions. 

What  are  the  advantages  of  the  Trendelenburg  position  ? 

Describe  a  method  of  shortening  the  round  ligaments  for  retroflexion. 

Give  the  origin  and  insertion  of  the  round  ligaments. 

What  variations  in  origin  are  met  with  ? 

Discuss  their  bearing  on  the  normal  position  of  the  uterus. 

Describe  the  technique  of  shortening  the  uterosacral  ligaments. 

What  are  the  indications  for  the  operation? 

Describe  the  operation  of  ventral  suspension. 

Discuss  its  merits. 

What  operative  procedures  should  be  carried  out  in  a  case  of  pro- 
cidentia? 

How  would  you  correct  the  condition  of  ovarian  prolapse? 

What  are  the  indications  for  salpingostomy  ? 

Describe  the  operation. 

Describe  the  operation  of  salpingectomy. 

What  precautions  should  be  taken  in  removing  a  pyosalpinx? 

In  what  cases  is  supravaginal  hysterectomy  preferable  to  complete 
removal  ? 

Describe  the  removal  of  a  pedunculated  fibroid. 

Discuss  the  indications  for  myomectomy  in  a  case  of  multiple  fibroids 
of  the  uterus. 

Describe  the  technique  of  closure  of  the  abdominal  incision  after 
operation. 

Discuss  the  after-treatment  of  a  case  of  abdominal  celiotomy. 


INDEX. 


A 


Abbey,  needle-holder,  152 
Abdominal  celiotomy,  182 

for  retrodisplacements  of  uter- 
us, 130 

examination,  32 

hysterectomy  in  abdominal  celi- 
otomy, 190 

retractor,  Child's,  153 
Eastman's,  154 
Abnormalities  of  Fallopian  tubes, 

92 
Abortion,     criminal,     diseases     of 

women  and,  29 
Abscess,  pelvic,  109 

tuboovarian,  94 
Actinomycosis  of  Fallopian  tubes, 
96 

of  labia  majora,  39 
Adenoma  of  ovary,  100 
Adenomyoma  of  uterus,  90 
Alexander-Adams     operation     for 

retrodisplacements  of  uterus,  129 
Amenorrhea,  112 

definition  of,  112 

diagnosis  of,  113 

etiology  of,  113 

pathology  of,  112 

symptoms  of,  113 

treatment  of,  113 
Amputation  of  cervix,  162 
Angiotribe,  Child's,  157 
Anteflexion  of  uterus,  139 
Atresia  of  cervix,  65 

of  \agina,  49,  50 

of  Aulva,  36 
Atrophy  of  cervix,  65 

of  uterus,  65 

14 


B 


Bartholin,  glands  of,  anatomy  of, 

21 
Bimanual  examination,  33 
Blood  supply  of  uterus,  24 


Carcinoma  of  cervix,  78 
of  uterus,  81 
of  vagina,  58 
of  vulva,  47 
Catarrh  of  cervix,  69 

of  vagina,  55 
Celiotomy,  abdominal,  182 
h3'sterectomy  in,  190 
care  of  wound  in,  197 
closure  of  wound  in,  194 
Child's  method,  194 
complete  removal  in,  192 
dressing  of  wound  in.  197 
indications  for,  189 
longitudinal,  183 
myomectomy  in,  194 
oophorectomy  in,  189 
oophorrhaphy  in,  189 
removal    of    pedunculated 

tumors  in,  193 
for  retrodisplacements,  187 
Gilliam's  operation,  188 
Goffe's  method,  187 
Kelly's  method,  187 
Mann's  method,  187 
of  uterus,  130 
salpingectomy  in,  190 
salpingostomy-  in,  189 
supravaginal  removal  in,  190 
(  209  ) 


210 


INDEX 


Celiotom}^,  abdominal,  transverse, 
183 
suprapubic,  184 
vaginal,  anterior,  176 

for  retrodisplacements,  178 
oophorectomy,  179 
salpingectomy,  179 
shortening  of  ovarian  liga- 
ments, 179 
of  round  ligaments  in, 
178 
vaginal  fixation  in,  178 
posterior,  180 
Cervix  uteri,  amputation  of,  162 
technique  of,  163 
atresia  of,  65 
atrophy  of,  65 
diagnosis  of,  66 
occurrence  of,  65 
symptoms  of,  66 
carcinoma  of,  78 
definition  of,  78 
diagnosis  of,  80 
etiology  of,  79 
pathology  of,  78 
symptoms  of,  80 
treatment  of,  80 
catarrh  of,  69 
acute,  69 
chronic,  69 
definition  of,  69 
diagnosis  of,  70 
etiology  of,  70 
pathology  of,  70 
symptoms  of,  70 
treatment  of,  70 
dilatation  of,  158 
hyperelongation  of,  67 
definition  of,  67 
diagnosis  of,  67 
etiology  of,  67 
pathology  of,  67 
S3miptoms  of,  67 
treatment  of,  68 
h3'pertrophy  of,  66 
diagnosis  of,  67 
etiology  of,  66 
patholog}?-  of,  66 
symptoms  of,  66 
treatment  of,  67 


Cervix  uteri,  laceration  of,  68 
anteroposterior,  68 
bilateral,  68 
definition  of,  68 
diagnosis  of,  69 
etiology  of,  68 
left  unilateral,  68 
patholog}^  of,  68 
stellate,  68 
S3^mptoms  of,  68 
treatment  of,  69 
varieties  of,  68 
malformations  of,  65 
Childbirth,  diseases  of  women  and, 

29 
Child's  abdominal  retractor,  153 
angiotribe,  157 
intestinal    forceps    with    rubber 

jaws,  157 
method  of  closure  of  wound  in 

abdominal  celiotomy,  194 
trowel  retractor,  156 
Civilization,  diseases  of  women  and, 

28 
Clamp,  Pean's  h3^sterectomy,  155 
Clitoris,  absence  of,  37 
anatom3^  of,  20 
bifid,  37 
Conception,  prevention  of,  diseases 

of  women  and,  29 
Condvlomata  acuminata,  43 
definition  of,  43 
diagnosis  of,  43 
etiolog3^  of,  43 
patholog3^  of,  43 
S3"mptoms  of,  43 
treatment  of,  43 
Curettage,  159 
Curette,  Sims',  152 
Cystocele,  144 
definition  of,  144 
diagnosis  of,  145 
etiology  of,  144 
operation  for,  166 
pathology  of,  144 
s3^mptoms  of,  145 
treatment  of,  146 
Cysts  of  ovary,  100 
of  vagina,  58 
of  vulva,  45 


INDEX 


211 


Deciduoma  malignum,  83 
definition  of,  83 
diagnosis  of,  83 
etiology  of,  83 
patliology  of,  83 
symptoms  of,  83 
treatment  of,  83 
Delayed  menstruation,  112 
Dermoid  cyst  of  ovary,  100 
Descensus  uteri,  132 
Deschamp's  ligature  carrier,  156 
Dilatation  of  cervix,  158 
Dilator,  Pryor's,  151 

Wathen's,  152 
Diphtheria  of  vagina,  55 

of  vulva,  38,  39 
Displacements  of  uterus,  120 
downward,  131 
lateral,  130 
Doyen's  traction  forceps,  151 

tumor  screw,  158 
Dress,  diseases  of  women  and,  28 
Dynamics  of  female  pelvis,  116 
Dysmenorrhea,  114 
definition  of,  114 
diagnosis  of,  115 
etiology  of,  115 
pathology  of,  114 
symptoms  of,  115 
theories  of,  114 
treatment  of,  115 
Dyspareunia,  57 


E 


Eastman's  retractor,  154 
Ectopic  gestation,  103 

definition  of,  103 
.  diagnosis  of,  after  rupture,  105 
before  rupture,  105 

etiology  of,  104 

pathology  of,  103 

symptoms  of,  104 

treatment  of,  106 
Elephantiasis  of  vulva,  46 
Emmet's  perineorrhaphy,  168 
Endocervicitis,  69 


Endometritis,  71 
acute,  71 

etiology  of^  71 
pathology  of,  71 
chronic,  74 

definition  of,  74 
diagnosis  of,  74 
etiology  of,  74 
pathology  of,  74 
symptoms  of,  74 
treatment  of,  74,  75 
definition  of,  71 
gonorrheal,  71 
diagnosis  of,  71 
symptoms  of,  71 
treatment  of,  71 
putrid,  72 

diagnosis  of,  73 
etiology  of,  72 
pathology  of,  72 
symptoms  of,  73 
treatment  of,  73 
septic  puerperal,  72 
diagnosis  of,  72 
symptoms  of,  72 
treatment  of,  72 
Enterovaginal  fistula,operation  for, 

176 
Epispadias,  36 
Erysipelas  of  vulva,  38,  39 
Extraperitoneal  operations  for  re- 
trodisplacements  of  uterus,  129 


F 


Fallopian  tubes,  abnormalities  of 
92 
actinomycosis  of,  96 
anatomy  of,  25 
arteries  of,  27 
infectious  granuloma  of,  96 

definition  of,  96 

diagnosis  of,  97 

etiology  of,  97 

pathology  of,  96 

symptoms  of,  97 

treatment  of,  97 
inflammations  of,  93 
neoplasms  of,  97 


212 


INDEX 


Fallopian  tubes,  syphilis  of,  96 

tuberculosis  of,  96 
Female  pelvis,  d3mamics  of,  116 
Fetal  life,  uterus  of,  25 
Fibroid  tumors  of  vagina,  58 
Fibroma  of  vulva,  46 
Fibromyoma  of  uterus,  84 
interstitial,  85 
submucous,  86 
subperitoneal,  86 
Fistula,     enterovaginal    operation 
for,  176 
genital,  147 

rectoiabial,  operation  for,  176 
rectoperineal,  operation  for,  176 
rectovaginal,  operation  for,  175 
ureterovaginal,     operation     for, 

175 
urethrovaginal,     operation    for, 

175 
vesico-uterine,  operation  for,  175 
vesicovaginal,  operation  for,  173 
Foerster's  sponge-holder,  152 
FoUicular  vulvitis,  38 
Forceps,  intestinal.  Child's,  157 
tissue,  154 

traction.  Doyen's,  151 
Frenum,  20 
Fritsch-Bozeman  uterine  irrigator, 

155 
Furunculosis  of  vulva,  38 


G 


Gangrene  of  vulva,  38 
Garrigues'  speculum,  154 
Genital  fistula,  147 

definition  of,  147 

diagnosis  of,  149 

etiology  of,  148 

operations  for,  173 

pathology  of,  147 

s^^mptoms  of,  148 

treatment  of,  149 
organs,  anatomy  of,  19 

development  of,  17 
Gilliam's  abdominal  celiotomy,  188 
Glands  of  Bartholin,  anatomv  of, 
21 


Goffe's  abdominal  celiotomy,  187 

perineorrhaphy,  169 
Gonorrhea  of  vagina,  55 
Gonorrheal  endometritis,  71 
Graafian  vesicles,  26 
Granular  vaginitis,  55 
Graves'    speculum,   34 
Gynecological  history,  29 
operations,  major,  151 
minor,  151,  156 

position  of  patient  in,  156 
preparation     of     surgeon's 
hands  for,  157 


H 


Hematemetra,  49 
Hematocele,  pelvic,  108 
Hematocolpos,  49,  713 
Hematoma  of  vulva,  43 
Hematosalpinx,  49 
Hemorrhage,  intermenstrual,  113 
Hermaphroditism,  37 
Hernia  of  uterus,  138 

of  vulva,  48 
Hydrosalpinx,  93 
Hymen,  absence  of,  37 

anatomy  of,  20 

double,  37 

imperforate,  37 
operation  for,  160 
Hyperelongation  of  cervix,  67 
Hypertrophy  of  cervix,  66 
Hypospadias,  36 

Hysterectomy,   abdominal,  in  ab- 
dominal celiotomy,  190 

clamp.  Bean's,  155 

vaginal,  181 


Imperforate    hvmen,     operation 

for,  160 
Inflammation  of  Fallopian  tubes, 
93 

of  ovaries,  98 

of  vagina,  54 

of  vulva,  37 


INDEX 


213 


Intertnenstrual  hemorrhage,  113 
Interstitial  fibromyoma  of  uterus, 

85 
Intestinal  forceps.  Child's,  157 
Intraperitoneal  operation  for  retro- 
displacements  of  uterus,  129 
Inversion  of  uterus,  136 


Kelly's  abdominal  celiotomy,  187 
Kraurosis  vulvae,  41 

definition  of,  41 

diagnosis  of,  42 

etiology  of,  41 

pathology  of,  41 

symptoms  of,  41 

treatment  of,  42 


Labia  majora,  actinomycosis  of,  39 
anatomy  of,  20 

minora,  anatomy  of,  20 
Lacerations  of  cervix,  68 

of  perineum,  141 
Ligaments,  ovarian,  27 

of  uterus,  23 


M 


Malformations  of  cervix  uteri,  65 

of  uterus,  60 

of  vagina,  49 

of  vulva,  36 
Mann's  abdominal  celiotomy,  187 
Martin's  uterine  sound,  153 
Menopause,  139 

definition  of,  139 

diagnosis  of,  140 

patholog}^  of,  140 

symptoms  of,  140 

treatment  of,  140 
Menorrhagia,  113 

definition  of,  113 

diagnosis  of,  114 

etiology  of,  113 


Menorrhagia,  pathology  of,  113 
S3'mptoms  of,  114 
treatment  of,  114 
Menstruation,  delayed,  112 
diseases  of  women  and,  28 
disorders  of.  111 
normal.  111 
premature,  111 

treatment  of,  112 
uterus  of,  25 
vicarious,  112 
Metritis,  75 
acute,  75 

diagnosis  of,  76 
etiology  of,  75 
pathology  of,  75 
symptoms  of,  75 
treatment  of,  76 
chronic,  76 
diagnosis,  77 
etiology  of,  76 
pathology  of,  76 
symptoms  of,  76 
treatment  of,  77 
definition  of,  75 
Metrorrhagia,  113 
Mons  veneris,  20 
Miiller,  ducts  of,  17 
Myomectomy  in  abdominal  celiot- 
omy, 194 


N 


Neoplasms  of  Fallopian  tubes,  97 
Nerves  of  uterus,  25 
Nymphsp,  20 


Oophorectomy  in  abdominal  celi- 
otomy, 189 
in  vaginal  celiotomy,  1 79 
Oophorrhaphy  in  abdominal  celi- 
otomy, 189 
Ovarian  ligament,  27 

shortening     of,     in     anterior 
vaginal  celiotomy,  179 
Ovaries,  adenoma  of,  100 


214 


INDEX 


Ovaries,  anatomy  of,  26 

arteries  of,  27 

cysts  of  dermoid,  100 
parovarian,  100 
simple  serous,  100 

displacement  of,  98 

inflammation  of,  98 

maldevelopment  of,  97 

papilloma  of,  100 

passive  congestion  of,  98 

prolapse  of,  98 
diagnosis  of,  99 
etiology  of,  99 
pathology  of,  98 
symptoms  of,  99 
treatment  of,  99 

rudimentary,  97 

structure  of,  26 

supernumerary,  97 

teratoma  of,  100 

tumors  of,  99 
diagnosis  of,  101 
malignant,  100 
pathology  of,  100 
symptoms  of,  101 
treatment  of,  102 
Ovaritis,  98 

acute,  98 

chronic,  98 

definition  of,  98 

diagnosis  of,  98 

etiology  of,  98 

pathology  of,  98 

symptoms  of,  98 

treatment  of,  98 
Oviducts,  25 


Papilloma  of  ovar}-,  100 

of  vulva,  42 
Parametrium,  diseases  of,  107 
Parovarian  cysts,  100 
Pean's  hysterectomy  clamp,  155 
Pelvic  abscess,  109 

definition  of,  109 

diagnosis  of,  110 

etiology  of,  109 

pathology  of,  109 


Pelvic  abscess,  symptoms  of,  110 

treatment  of,  110 
hematocele,  108 

definition  of,  108 

diagnosis  of,  108 

etiology  of,  108 

pathology  of,  108 

symptoms  of,  108 

treatment  of,  109 
peritonitis,  107 

acute,  107,  108 

chronic,  107,  108 

definition  of,  107 

diagnosis  of,  107 

etiology  of,  107 

pathology  of,  107 

symptoms  of,  107 

treatment  of,  108 
Pelvis,  female,  dynamics  of,  116 
Perineorrhaphy,  167 
after-treatment  of,  173 
Emmet's,  168 
Goffe's,  169 
Ristine's,  171 
Perineum,  anatomy  of,  20 
lacerations  of,  141 

definitions  of,  141 

diagnosis  of,  143 

etiology  of,  142 

pathology  of,  142 

symptoms  of,  143 

treatment  of,  144 
Peritonitis,  pelvic,  107 
Pessary,   Skene's,    146 
Polyps  of  uterus,  90 
Pregnancy,  uterus  of,  25 
Premature  menstruation,  111 
Prepuce,  20 
Procidentia,  132 
Prolapse  of  ovary,  98 

of  uterus,  132 
Pruritus  vulva^,  40 

definition  of,  40 

diagnosis  of,  40 

etiology  of,  40 

pathology  of,  40 

symptoms  of,  40 

treatment  of,  41 
Pryor's  dilator,  151 
Pseudohermaphroditism,  37 


INDEX 


215 


puerperal  \iilvitis,  38 
Putrid  endometritis,  72 
Pyosalpinx,  93 
treatment  of,  96 


Rectal  examination,  35 
Rectocele,  146 

definition  of,  146 

diagnosis  of,  147 

etiology  of,  147 

pathology  of,  146 

symptoms  of,  147 

treatment  of,  147 
Rectolabial  fistula,  operation  for, 

176 
Rectovaginal  fistula,  operation  for, 

175 
Relaxation  of  vaginal  outlet,  141 
Retrodisplacements  of  uterus,  121 
Ristine's  perineorrhaphy,  171 
Round  ligaments,  shortening  of,  in 

anterior  vaginal  celiotomy,  178 


Salpingectomy  in  vaginal  celiot- 
omy, 179 

Salpingitis,  93 

acute,  treatment  of,  95 
chronic,  treatment  of,  96 
diagnosis  of,  95 
etiology  of,  94 
pathology  of,  93 
symptoms  of,  95 
treatment  of,  95 

Salpingostomy  in  abdominal  celi- 
otomy, 189,  190 

Sarcoma  of  uterus,  82 
of  vagina,  59 
of  vulva,  48 

Senile  vaginitis,  55 

Septic  puerperal  endometritis,  72 

Sims'  curette,  152 
speculum,  35 
tampon  screw,  153 

Skene's  pessary,  146 


Speculum,  examination  with,  35 

Garrigues',  154 

Graves',  34 

Sims',  35 
Sterility,  149 

absolute,  149 

definition  of,  149 

etiology  of,  149 

relative,  149 

treatment  of,  150 
Subinvolution  of  uterus,  92 
Submucous  fibromvoma  of  uterus, 

86 
Subperitoneal  fibromyoma  of  ute- 
rus, 86 
Superinvolution  of  uterus,  77 
Syphilis,  diseases  of  women  and,  29 

of  Fallopian  tubes,  96 

of  vulva,  39 


Teratoma  of  ovary,  100 
Tissue  forceps,  154 
Trachelorrhaphy,  160 
Traction  forceps.  Doyen's,  151 
Trowel  retractor,  156 

Child's,  156 
Tubal  gestation,  97 
Tuberculosis  of  Fallopian  tubes,  96 
of  uterus,  91 
of  vagina,  59 
of  vulva,  39 
Tuboovarian  abscess,  94 

treatment  of,  96 
Tumors  of  ovary,  99 
of  uterus,  benign,  84 

malignant,  78 
of  vagina,  57 
fibroid,  58 
of  vulva,  benign,  46 
malignant,  47 
Tumor  screw,  Doyen's,  158 

U 

Ulcers,  venereal,  of  vulva,  42 
ITreterovaginal    fistula,    operation 
for,  175 


216 


INDEX 


Urethrovaginal    fistula,    operation 

for,  175 
Uterine     irrigator,     Fritsch-Boze- 

man,   155 
sound,  Martin's,  153 
Uterus,  absence  of,  60 
adenomyoma  of,  90 

definition  of,  90 

diagnosis  of,  90 

etiology  of,  90 

pathology  of,  90 

symptoms  of,  90 

treatment  of,  90 
anatomy  of,  22 
anteflexion  of,  139 

definition  of,  139 

diagnosis  of,  139 

etiology  of,  139 

pathology  of,  139 

symptoms  of,  139 

treatment  of,  139 
appendages  of,  25 
atrophy  of,  65 

diagnosis  of,  66 

occurrence  of,  65 

symptoms  of,  66 
bicornis,  61 
bipartitus,  61 
blood  supply  of,  24 
carcinoma  of,  81 

definition  of,  81 

diagnosis  of,  81 

etiology  of,  81 

pathology  of,  81 

s3^mptoms  of,  81 

treatment  of,  82 
cavity  of,  24 
coats  of,  24 
didelphys,  61 
displacements  of,  120 

major,  121 

minor,  120 
downward  displacements  of,  131 
definition  of,  131 
diagnosis  of,  134,  135 
etiology  of,  134 
pathology  of,  132 
symptoms  of,  134 
treatment  of,  135 

'    varieties  of,  132 


Uterus  of  fetal  life,  25 

fibromyoma  of,  84 
definition  of,  84 
diagnosis  of,  87 
etiology  of,  87 
frequency  of,  84 
interstitial,  85 
pathology  of,  84 
submucous,  86 
subperitoneal,  86 
symptoms  of,  87 
treatment  of,  88 
varieties  of,  84 

hernia  of,  138 

infantilis,  62 

inversion  of,  136 
acute,  136 
chronic,  136 
definition  of,  136 
diagnosis  of,  137 
etiology  of,  137 
pathology  of,  136 
symptoms  of,  137 
treatment  of,  137 

lateral  deviations  of,  130 
treatment  of,  131 

ligaments  of,  23 

malformations  of,  60 
diagnosis  of,  64 
etiology  of,  62 
pathology  of,  60 
symptoms  of,  64 
treatment  of,  65 

of  menstruation,  25 

nerves  of,  25 

of  old  age,  25 

polyps  of,  90 
diagnosis  of,  91 
etiology  of,  91 
pathology  of,  91 
symptoms  of,  91 
treatment  of,  91 

of  pregnancy,  25 

prolapse  of,  132 
complete,  132 
diagnosis  of,  135 
treatment  of,  136 
incomplete,  132 
diagnosis  of,  134 
treatment  of,  135 


INDEX 


217 


Uterus,  retrodisplacements  of,  121 
definition  of,  121 
diagnosis  of,  122 
etiology  of,  121 
pathology  of,  121 
symptoms  of,  121 
treatment  of,  124 

abdominal     celiotomy     in, 

187 
extraperitoneal  methods, 
129 
Alexander-Adams  oper- 
ation, 129 
vaginal  fixation,  129 
intraperitoneal    methods, 
129 
abdominal     celiotomy, 

130 
vaginal  celiotomy,  129 
introduction   of   pesary   in, 

127 
operative,  128 
reposition,    bimanual 
method,  126 
gravity  method,  126 
vaginal  method,  124 
vaginal  celiotomv,  anterior, 
in,  178 
rudimentary,  60 
sarcoma  of,  82 
definition  of,  82 
diagnosis  of,  82 
etiolog^^  of,  82 
pathology  of,  82 
symptoms  of,  82 
treatment  of,  83 
septus,  62 

subinvolution  of,  92 
definition  of,  92 
diagnosis  of,  92 
pathology  of,  92 
symptoms  of,  92 
treatment  of,  92 
superinx'olution  of,  77 
definition  of,  77 
diagnosis  of,  78 
etiology  of,  78 
pathology  of,  77 
prognosis  of,  78 
symptoms  of,  78 


Uterus,  superinvolution  of,  treat- 
ment of,  78 

tuberculosis  of,  91 
diagnosis  of,  92 
symptoms  of,  91 
treatment  of,  92 

tumors  of,  benign,  84 
malignant,  78 

unicornis,  61 


Vagina,  absence  of,  49 
anatomy  of,  21 
atresia  of,  49,  50,  51 

definition  of,  50 

diagnosis  of,  53 

etiology  of,  50 

hymenalis,  51 

pathology  of,  51 

symptoms  of,  52 

treatment  of,  54 
carcinoma  of,  58 

definition  of,  58 

diagnosis  of,  59 

etiology  of,  58 

pathology  of,  59 

symptoms  of,  59 

treatment  of,  59 
cysts  of,  b^ 

diagnosis  of,  58 

etiology  of,  58 

occurrence  of,  58 

pathology  of,  58 

symptoms  of,  58 

treatment  of,  58 
double,  49 

hour-glass  contraction  of,  49 
inflammation  of,  54 
malformations  of,  49 
sarcoma  of,  59 

occurrence  of,  59 

symptoms  of,  59 
tuberculosis  of,  59 

occurrence  of,  50 
tumors  of,  57 

fibroid,  58 

diagnosis  of,  58 


218 


INDEX 


Vagina,  tumors  of,  fibroid,  etiology 
of,  58 
pathology  of,  5S 
s3^mptoms  of,  58 
treatment  of,  58 
^'^aginal  celiotomy,  anterior,  176 
posterior,  180 

for  retrodisplacements,    ante- 
rior, 178 
of  uterus,  129 
examination,  32 
fixation  in  anterior  vaginal  celi- 
otomj^,  178 
in  retrodisplacements  of  uter- 
us, 129 
hysterectomy,  181 
outlet,  relaxation  of,  141 
definition  of,  141 
diagnosis  of,  141 
etiology  of,  141 
pathology  of,  141 
symptoms  of,  141 
treatment  of,  141 
Vaginismus,  57 
definition  of,  57 
diagnosis  of,  57 
etiology  of,  57 
symptoms  of,  57 
treatment  of,  57 
Vaginitis,  54 
catarrhal,  55 
definition  of,  54 
diagnosis  of,  56 
diphtheritic,  55 
etiolog}'  of,  54 
gonorrheal,  55 
granular,  55 
pathology  of,  54 
senile,  55 
symptoms  of,  55 
treatment  of,  56 
varieties  of,  55 
Varicocele  of  vulva,  44 
Venereal  ulcers  of  vulva,  42 
Vesico-uterine  fistula,operation  for. 

175 
Vesicovaginal  fistula,  operation  for, 

173 
Vestibule,  anatomy  of,  20 
Vulva,  absence  of,  36 


Vulva,  atresia  of,  36 
carcinoma  of,  47 
cysts  of,  45 

definition  of,  45 
diagnosis  of,  45 
etiology  of,  45 
pathology  of,  45 
symptoms  of,  45 
treatment  of,  45 
t3'pes  of,  45 
double,  36 
elephantiasis  of,  46 
definition  of,  46 
diagnosis  of,  46 
etiology  of,  46 
pathology  of,  46 
symptoms  of,  46 
treatment  of,  46 
fibroma  of,  46 
hematoma  of,  43 
definition  of,  43 
diagnosis  of,  44 
etiology  of,  43 
pathology  of,  43 
symptoms  of,  44 
treatment  of,  44 
hernia  of,  48 
definition  of,  48 
diagnosis  of,  48 
etiolog}^  of,  48 
pathology  of,  48 
symptom.s  of,  48 
treatment  of,  49 
infantile,  36 
inflammation  of,  37 
malformations  of,  36 
papilloma  of,  42 
sarcoma  of,  48 
tumors  of,  benign,  46 
diagnosis  of,  47 
etiology  of,  46 
pathology  of,  46 
symptoms  of,  47 
treatment  of,  47 
type  of,  46 
malignant,  47 
diagnosis  of,  48 
etiology  of,  47 
pathology  of,  47 
prognosis  of,  48 


INDEX 


219 


Vulva,  tumors  of,  malignant,  symp- 
toms of,  47 
treatment  of,  48 
varieties  of,  47 
varicocele  of,  44 
definition  of,  44 
diagnosis  of,  44 
etiology  of,  44 
pathology  of,  44 
symptoms  of,  44 
treatment  of,  44 
venereal  ulcers  of,  42 
Vulvitis,  37 

definition  of,  37 
diagnosis  of,  38 
diphtheritic,  38,  39 
erysipelatous,  38,  39 


Vulvitis,  etiology  of,  38 
follicular,  38 
furuncular,  38 
gangrenous,  38 
pathology  of,  38 
puerperal,  38 
symptoms  of,  38 
syphilitic,  39 
treatment  of,  39 
tuberculous,  39 


W 

"Wathen's  dilator,  152 
Wolffian  bodies,  17 
ducts,  17 


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